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Preventing Medication Errors (2007)

Chapter: Appendix C Medication Errors: Incidence Rates

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Suggested Citation:"Appendix C Medication Errors: Incidence Rates ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
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C
Medication Errors: Incidence Rates

This appendix reviews estimates of the rates of medication errors and adverse drug events (ADEs) in three care settings (hospital, nursing home, and ambulatory care) and in pediatric and psychiatric care. Where possible, error rates for the five stages of the medication-use system and at the interface between care settings are documented separately.

INCIDENCE OF MEDICATION ERRORS IN HOSPITAL CARE

Selection and Procurement of the Drug by the Pharmacy

No studies were identified that specifically identified medication errors of this type. It is possible that these types of errors were included in studies of general medication error rates.

Prescription and Selection of the Drug for the Patient: Errors of Commission

Rates of prescribing errors (for example, dosing errors, prescribing medications to which the patient was allergic, prescribing inappropriate dosage forms) vary considerably from study to study and are quoted in several different ways—errors per 1,000 admissions, errors per 1,000 orders, errors per 100 opportunities for error, and preventable ADEs per 1,000 admissions (see Table C-1):

Suggested Citation:"Appendix C Medication Errors: Incidence Rates ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
×

TABLE C-1 Hospital Care: Prescription and Selection Errors of Commission

Error rates

Per 1,000 admissions—detection method

12.3 (Lesar, 2002a)—pharmacist review of written orders

29 (Winterstein et al., 2004)—prompted reporting

52.9 (Lesar et al., 1997)—pharmacist review of written orders

190 (LaPointe and Jollis, 2003)—clinical pharmacist directly participating in clinical care

1,400 (Bates et al., 1995a)—prompted reporting, chart review, review of medication orders

 

Per 1,000 orders—detection methods

0.61 (Lesar, 2002a)—pharmacist review of written orders

2.87 (Lesar et al., 1997)—pharmacist review of written orders

3.13 (Lesar et al., 1990)—pharmacist review of written orders

53 (Bates et al., 1995a)—prompted reporting, chart review, review of medication orders

 

Per 100 opportunities for error—detection method

1.5 (Dean et al., 2002)—pharmacist review of written orders

6.2 (Bobb et al., 2004)—pharmacist review of written orders

6.7 (Lisby et al., 2005)—direct observation, unannounced control visits, chart review

9.9 (van den Bemt et al., 2002)—pharmacist review of written orders

Preventable ADEs rates

Per 1,000 admissions—detection method

3.7 (Hardmeier et al., 2004)—chart review

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

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

  • Prescribing errors totaled 12.3 to 1,400.0 per 1,000 patient admissions: (1) 12.3 in a study of 32,683 admissions in a tertiary care hospital in New York State (Lesar, 2002a); (2) 29 in a study of about 6,000 patients in a tertiary care hospital in Florida (Winterstein et al., 2004); (3) 52.9 in a study of 211,635 admissions in a tertiary care hospital in New York State (Lesar et al., 1997); (4) 190.0 in a study of 24,538 patients in a tertiary care hospital in North Carolina (LaPointe and Jollis, 2003); and (5) 1,400 in a study of 379 patients in an urban tertiary care hospital in Massachusetts (Bates et al., 1995a).

  • Prescribing errors occurred per order at rates ranging from 0.6 to 53 per 1,000 orders (Lesar et al., 1990; Bates et al., 1995a; Lesar et al., 1997; Lesar, 2002a).

  • Errors per 100 opportunities for error ranged from 1.5 to 9.9 (van den Bemt et al., 2002; Dean et al., 2002; Bobb et al., 2004; Lisby et al., 2005).

Suggested Citation:"Appendix C Medication Errors: Incidence Rates ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
×

In the subset of studies that evaluated preventable ADEs, prescription errors associated with patient injuries ranged from 3.7 to 84.1 per 1,000 admissions (Bates et al., 1995b; Hardmeier et al., 2004; Nebeker et al., 2005).

Preparation and Dispensing of the Drug

Preparation and dispensing errors occurred at a rate of 2.6 per 1,000 admissions in a tertiary care hospital in Florida (Winterstein et al., 2004) (see Table C-2).

Two studies focused exclusively on intravenous (IV) medications. One study, at one U.K. and two German hospitals, found a rate of preparation errors of 26 percent per observed preparation (88 preparation errors out of 337 observations) (Wirtz et al., 2003). The other study, at a tertiary and a community hospital in the United Kingdom, found a rate of preparation errors of 49 percent per observed preparation (212 preparation and administration errors out of 430 doses) (Taxis and Barber, 2003).

Preparation and dispensing errors were associated with preventable ADEs at rates of 0.6 per 1,000 admissions in a Swiss study of 6,383 patients (Hardmeier et al., 2004); 1.1 per 1,000 admissions in a study of 4,031 patients at two tertiary hospitals in Boston, Massachusetts (Bates et al., 1995b); and 1.6 per 1,000 admissions in a study of 937 admissions at a tertiary hospital in Salt Lake City, Utah (Nebeker et al., 2005).

Administration of the Drug

As with prescribing error rates, rates of administration errors varied widely in medical and surgical units (See Table C-3). Rates per opportunity

TABLE C-2 Hospital Care: Preparation and Dispensing Errors

Error rates: general medications

Per 1,000 admissions—detection method

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

Error rates: intravenous (IV) medications

Per preparation—detection method

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

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

Preventable ADEs

Per 1,000 admissions—detection method

0.6 (Hardmeier et al., 2004) (Swiss study)—chart review

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

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

Suggested Citation:"Appendix C Medication Errors: Incidence Rates ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
×

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).

Suggested Citation:"Appendix C Medication Errors: Incidence Rates ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
×

Another study, in a tertiary hospital in Florida, involving about 6,000 patients (the authors could not report precisely the number of patients involved), found an administration error rate of 5.8 per 1,000 admissions (Winterstein et al., 2004).

Similar rates to those above have been observed in intensive care unit (ICU) studies. In a study focusing on high-alert medications administered in ICUs in five U.S. tertiary care teaching hospitals, an administration error rate of 3.3 percent was found (5,744 observations) (Calabrese et al., 2001). In another study, carried out in a medical ICU in a French hospital, an administration error rate of 6.6 percent was observed (2,009 medication administration interventions by nurses) (Tissot et al., 1999).

Higher rates were seen in studies that focused exclusively on IV medications—34 percent (93 errors out of 278 observed administrations) (Wirtz et al., 2003) and 49 percent (212 preparation and administration errors out of 430 doses) (Taxis and Barber, 2003).

Two studies looking at preventable ADEs occurring during the administration stage found rates of 2.1 per 1,000 admissions (in a study of 4,031 patients at two tertiary hospitals in Boston, Massachusetts [Bates et al., 1995b]) and 17.9 per 1,000 admissions (in a study of 937 admissions at a tertiary hospital in Salt Lake City, Utah [Bates et al., 1995b; Nebeker et al., 2005]).

Monitoring of the Patient for Effect

Rates of preventable ADEs resulting from errors in the monitoring of patients were reported in two studies as 0.6 per 1,000 admissions (Hardmeier et al., 2004) and 32 per 1,000 admissions (Hardmeier et al., 2004; Nebeker et al., 2005). (See Table C-4).

ADEs during Hospitalization

Five major studies examined the incidence of ADEs occurring during hospitalization (see Table C-5). Using hospital admissions during the period 1990–1993, investigators at LDS Hospital, Salt Lake City, Utah, found that 2,227 out of 91,574 patients experienced ADEs during hospitalization, a rate of 2.43 ADEs per 100 admissions (Classen et al., 1997). Almost 50 percent of the identified ADEs were thought to be preventable. Extrapolat-

TABLE C-4 Hospital Care: Monitoring Errors

Preventable ADEs

Per 1,000 admissions—detection method

0.6 (Hardmeier et al., 2004) (Swiss study)—chart review

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

Suggested Citation:"Appendix C Medication Errors: Incidence Rates ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
×

TABLE C-5 Hospital Care: ADE Incidence During Hospitalization

Study

ADEs per 100 Admissions

ADEs per 1,000 Patient-Days

Proportion of ADEs Preventable

Classen et al., 1997

2.4

Not given

About 50 percent (out of 2,227 ADEs in study)

Senst et al., 2001

4.2

Not given

15 percent (out of 74 ADEs in the study

Bates et al., 1995b

6.5

11.5

28 percent (out of 247 ADEs in study)

Jha et al., 1998

Not given

21

27 percent (out of 617 ADEs in study)

Nebeker et al., 2005

52

70

27 percent (out of 483 ADEs in study)

ing these figures nationally and assuming 32 million admissions annually, the authors concluded that 770,000 hospital patients in America would experience an ADE annually.

Another study, conducted at two tertiary care hospitals in Boston, involved 4,031 adult admissions. Carried out in 1993 under the Adverse Drug Events Prevention Study, this study found an overall ADE rate of 6.5 per 100 nonobstetric admissions (or 11.5 ADEs per 1,000 patient-days); of these, 28 percent were judged preventable (Bates et al., 1995b). Of the ADEs, 1 percent were fatal (none preventable), 12 percent life-threatening, 30 percent serious, and 57 percent significant. Of the life-threatening and serious ADEs, 42 percent were judged preventable. Assuming an ADE rate of 6.5 per 100 nonobstetric admissions and 25 million nonobstetric admissions to short-term hospitals annually, the authors estimated an annual rate of 1.6 million ADEs in U.S. hospitals.

A third study, utilizing data on ADEs collected in the summer of 1998 from a four-hospital academic medical network, estimated the ADE rate during hospitalization to be 4.2 per 100 admissions (Senst et al., 2001). Fifteen percent of these ADEs were judged preventable.

At a tertiary hospital in Boston, in a study carried out from October 1994 to May 1995, 617 ADEs were observed, 166 of which were judged preventable (Jha et al., 1998). After adjustment for the sampling scheme, the ADE rate was estimated to be 21 per 1,000 patient-days.

Much higher ADE rates were observed in the most recent study, involving a highly computerized hospital that had implemented electronic health records (Nebeker et al., 2005). Computerized order checking was fully functional for allergies, many drug–drug interactions, and limited drug– disease interactions. The system did not, however, feature sophisticated decision-support algorithms. Among 937 hospital admissions, 483 clinically significant inpatients ADEs were identified—52 per 100 admissions,

Suggested Citation:"Appendix C Medication Errors: Incidence Rates ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
×

or 70 per 1,000 patient-days. Medication errors contributed to 27 percent of the ADEs. Of all the ADEs, 9 percent resulted in serious harm, 22 percent in additional monitoring and interventions, 32 percent in interventions alone, and 11 percent in monitoring alone; 27 percent should have resulted in additional interventions or monitoring.

Three smaller studies found similar ADE rates. A 37-day study at a Boston tertiary hospital found 27 ADEs (15 considered preventable), for a rate of 6.4 ADEs per 100 admissions or 9.1 ADEs per 1,000 patient-days (Bates et al., 1993). Another small study at the same hospital found 25 ADEs (5 considered preventable), for a rate of 6.6 ADEs per 100 admissions or 14.7 ADEs per 1,000 patient-days (Bates et al., 1995a). In a study of 157 hospitalized patients aged 70 and older, 28 probable ADEs were observed, for a rate of 17.8 ADEs per 100 admissions (Gray et al., 1998). Just over half the ADEs were considered preventable.

Prescription and Selection of the Drug for the Patient: Errors of Omission

Errors of omission occur when a medication necessary for the appropriate care of hospitalized individuals is not prescribed. After reviewing the published literature on medication errors of omission within acute care, the committee identified three broad categories of studies: studies on treatment of acute coronary syndromes, on antibiotic prophylaxis, and on thrombosis prophylaxis (see Table C-6).

TABLE C-6 Hospital Care: Prescription and Selection Errors of Omission

Patients discharged with diagnosis of acute myocardial infarction

Percentage of patients given aspirin within 24 hours of hospitalization

84.9 (Roe et al., 2005) (NSTEMI)

88 (Roe et al., 2005) (STEMI)

92.4 (Granger et al., 2005)

93 (Sanborn et al., 2004)

 

Percentage of patients prescribed aspirin at discharge

53 (Krumholz et al., 2003)

76.8 (Petersen et al., 2001)

83.8 (Roe et al., 2005) (NSTEMI)

84.8 (Petersen et al., 2003)

85.6 (Alexander et al., 1998)

88.9 (Roe et al., 2005) (STEMI)

93.4 (Granger et al., 2005)

Suggested Citation:"Appendix C Medication Errors: Incidence Rates ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
×

 

Percentage of patients given beta-blockers within 24 hours of hospitalization

66 (Sanborn et al., 2004)

72.2 (Roe et al., 2005) (NSTEMI)

77.8 (Roe et al., 2005) (STEMI)

78 (Granger et al., 2005)

 

Percentage of patients prescribed beta-blockers at discharge

53 (Krumholz et al., 2003)

56.1 (Petersen et al., 2001)

59.1 (Alexander et al., 1998)

67.3 (Petersen et al., 2003)

78.3 (Roe et al., 2005) (NSTEMI)

78.9 (Granger et al., 2005)

83.4 (Roe et al., 2005) (STEMI)

 

Percentage of patients prescribed angiotensin-converting enzyme (ACE) inhibitors at discharge

51.2 (Roe et al., 2005) (NSTEMI)

51.7 (Alexander et al., 1998)

58 (Roe et al., 2005) (78) (STEMI)

58.5 (Petersen et al., 2001)

67.6 (Petersen et al., 2003)

73.1 (Granger et al., 2005)

Rates of antibiotic prophylaxis within surgical studies

Percentage of procedures in which patients prescribed antibiotics

70 (Vaisbrud et al., 1999)

74 (Heineck et al., 1999)

92 (Gupta et al., 2003)

95 (Bedouch et al., 2004)

97 (van Kasteren et al., 2003)

97.5 (Quenon et al., 2004)

Rates of thromboembolic prophylaxis within surgical studies

Percentage of procedures in which thromboembolic prophylaxis carried out

5 at high risk, 23.0 at medium risk (Ahmad et al., 2002)

22 (Aujesky et al., 2002)

29 (Scott et al., 2003)

31.5 at the highest risk, 81 at high risk, 93 at moderate risk (Tan and Tan, 2004)

46.4 (Ageno et al., 2002)

49.4 (Chopard et al., 2005)

71 (Learhinan and Alderman, 2003)

81 (Freeman et al., 2002)

90 (Campbell et al., 2001)

NOTE: STEMI = acute ST-segment elevation myocardial infarction; NSTEMI = non-STEMI.

Suggested Citation:"Appendix C Medication Errors: Incidence Rates ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
×
Acute Coronary Syndromes

The committee reviewed seven studies on quality of care for acute myocardial infarction. Six of these studies determined prescription rates for indicated medications at discharge (Alexander et al., 1998; Petersen et al., 2001; Krumholz et al., 2003; Petersen et al., 2003; Roe et al., 2005; Granger et al., 2005). For patients discharged with a diagnosis of acute myocardial infarction, aspirin was prescribed to 53 to 93.4 percent of ideal candidates (those with no known contraindication). Beta-blockers were prescribed to 53 to 83.4 percent of ideal candidates, and angiotensin converting enzyme (ACE) inhibitors to 58.5 to 83.4 percent of ideal candidates. Three studies described rates of aspirin and beta-blocker use within the first 24 hours of hospitalization (Sanborn et al., 2004; Roe et al., 2005; Granger et al., 2005). Within the first 24 hours of hospitalization for a myocardial infarction, 66 to 78 percent of patients had received beta-blockers and 84.9 to 93 percent aspirin.

Antibiotic Prophylaxis

The committee identified six studies that described rates of antibiotic prophylaxis for surgical procedures (Heineck et al., 1999; Vaisbrud et al., 1999; van Kasteren et al., 2003; Gupta et al., 2003; Bedouch et al., 2004; Quenon et al., 2004). Rates of antibiotic prophylaxis ranged from 70 to 98 percent within the surgical studies. Although the rates of prescribing any antibiotic were high, antibiotic prophylaxis for surgical procedures requires that the appropriate antibiotic be selected, that the appropriate dose be prescribed, that the drug be administered at the appropriate time, and that the duration of therapy be correct. Absolute compliance with all of these elements of drug therapy was much lower—as low 3 percent in one study (Gupta et al., 2003).

Thrombosis Prophylaxis

The committee identified nine studies that determined rates of thromboembolic prophylaxis in at-risk hospitalized patients (Campbell et al., 2001; Ageno et al., 2002; Ahmad et al., 2002; Aujesky et al., 2002; Freeman et al., 2002; Learhinan and Alderman, 2003; Scott et al., 2003; Tan and Tan, 2004; Chopard et al., 2005). Thromboembolic prophylaxis includes both mechanical means, such as lower-extremity compression hose, and pharmacological means, such as subcutaneous heparin. Because medications are recommended in individuals at high risk for thrombosis, the committee included these studies.

Suggested Citation:"Appendix C Medication Errors: Incidence Rates ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
×

Rates of thromboembolic prophylaxis varied widely—from 5 to 81 percent. Rates of appropriate thromboembolic prophylaxis tended to be higher in surgical patients and in those at lower risk for thrombosis. One study also noted that thromboembolic prophylaxis was prescribed inappropriately in 38 percent of patients without risk factors for thrombosis (Aujesky et al., 2002).

INCIDENCE OF MEDICATION ERRORS IN NURSING HOMES

Studies on the incidence of medication errors and ADEs in nursing homes use a number of different definitions, measures, and metrics. Hence, as with hospital studies, it is difficult to compare the results across studies.

Drug Procurement and Dispensing

Drug procurement and dispensing in the nursing home differ from hospital practice because the pharmacy is generally offsite. Handler and colleagues (2004) identified several aspects of drug delivery: (1) issues of packaging (e.g., patient-specific unit-dose packaging, patient-specific blister packages, 7-day strips of medication, color-coded drug administration devices, or medication bottles similar to usual community practice); (2) access to urgent medications, such as stock drugs in an emergency box; and (3) drug delivery when medications are added or changed, which may require hours to days (Handler et al., 2004). There is minimal research on how the approaches to addressing these issues affect medication safety.

When several pharmacies provide medications to a single nursing facility, staff must learn to use numerous systems, a practice that violates the fundamental safety principle of standardization. An evaluation of the medication-use system in one nursing home found that the facility’s 72 patients were served by seven pharmacies, and the consultant pharmacist had no relationship with any of them (Cooper, 1987). The charge nurse verifying refill needs required 8–12 hours per 100 beds per month. Qualitative data underscore the issues of time and error associated with this refill process (Vogelsmeier et al., 2005). Gupta and colleagues (1996a,b) noted that only 8.4 percent of the 19,932 Medicaid patients they studied used a single pharmacy, and the number of pharmacies used was associated with mortality rates (Gupta et al., 1996a,b).

Administration Errors

The committee identified a few studies that measured the incidence of medication administration errors in nursing homes (see Table C-7). A well-known early study using direct observation of medication administration in

Suggested Citation:"Appendix C Medication Errors: Incidence Rates ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
×

TABLE C-7 Nursing Home: Administration Errors

Error rates

Per 100 opportunities/doses—detection method

6 (Cooper et al., 1994)—direct observation

12.2 (Barker et al., 1982)—direct observation

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

20 (Baldwin, 1992)—direct observation

58 nursing homes identified a mean error rate of 12.2 percent (range 0–59 percent over the 58 nursing homes), where an error was defined as a dose administered or omitted that deviates from the physician’s orders (Barker et al., 1982). The direct observation procedure used in this study detects primarily errors in transcribing and administration. If out-of-date and unsigned orders were excluded, the error rate was 8 percent. The most common error types were unauthorized drug (44.8 percent) and omission (41.5 percent), followed by wrong dose (11 percent), wrong route (2 percent), and wrong form (0.4 percent). Most of the errors involving unauthorized drugs were due to out-of-date orders. Wrong-time errors were not recorded in this study. Because an error is defined as a discrepancy between the drug ordered and the drug received, errors detected by observation may be due to transcription or administration error, but observational studies do not distinguish the phase in which the error originates.

In a 2-year study apparently using observation in one nursing home, Cooper (1987) also concluded that omissions were the most common type of administration error (65 percent of errors). Many of the omissions were caused by patient refusal or sleeping, but the charting often implied that the drug had been administered.

A later study of error rates in skilled nursing facilities and hospitals found an average rate of 21.6 percent in 12 skilled nursing facilities in Georgia and Colorado, using the same direct observation method of error detection and defining an error as a discrepancy between the dose ordered and the dose received. The range of error rates across the 12 nursing facilities was 5.7 to 49.5 percent. The average error rate was not statistically different from the 14.4 percent rate for hospitals (Barker et al., 2002). Excluding wrong-time errors, the rate was 14.7 percent for skilled nursing facilities and 9.9 percent for hospitals. About 7 percent of the errors were judged by a physician panel to be potential ADEs. The rank order of error types was wrong time (9.9 percent of doses, 45.4 percent of errors), omission (7 percent of doses, 32.4 percent of errors), and wrong dose (3.1 percent of doses, 14.2 percent of errors).

Using similar observational methods, Baldwin (1992) detected a 20 percent medication administration error rate in a study of 733 residents of 35 domiciliary homes in North Carolina (error rate range 3–44 percent

Suggested Citation:"Appendix C Medication Errors: Incidence Rates ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
×

across the 35 homes). Using observation of 300 doses, Cooper and colleagues (1994) found a 6 percent administration error rate in one 300-bed nursing home during the baseline evaluation, using observation of 300 doses prior to implementation of an automated system.

Wrong-time error is a significant problem in residential care settings. An error rate of 27 percent in assisted-living settings was reduced to 15 percent when a 4-hour interval (as opposed to a 2-hour interval) around the scheduled time was used to designate on-time administration (Young et al., 2005). Four types of error were observed: wrong time (43 percent of errors), wrong dose (30 percent), omitted dose (10 percent), and unauthorized drug (10 percent). Wrong-time errors were even more prevalent in nursing homes, where the error rate decreased from 35.6 to 6.7 percent when wrong-time errors were excluded (Scott-Cawiezell et al., 2005).

Transcription and Documentation

Errors identified by observation of drug administration, which detects errors in transcription as well as administration, are described in the section below on administration. A study of discrepancies in medication orders on documents (medication administration record, hospital summary, and discharge orders) accompanying 20 newly admitted residents at the time of transfer from a Veterans Administration hospital to a Veterans Administration nursing home revealed at least one medication discrepancy for every subject (Siple and Joseph, 1992). Discrepancies were found in medication name, medication dose, omitted or added medications, and instructions for use. Investigators attributed 75 percent of the discrepancies to error and 25 percent to intentional changes.

Monitoring

Although the committee could identify no studies focused specifically on monitoring errors, Gurwitz and colleagues (2005) pointed out that the high rate of preventable ADEs (4.1 per 100 patient months) identified in their cohort study of long-term residents of two academic nursing homes argued for a special focus on ordering and monitoring. Errors occurred at the monitoring stage in 80 percent of the preventable ADEs. The most common monitoring errors were inadequate monitoring and failure to act on monitoring.

Comparison of Error Rates Across Stages of the Medication-Use Process

Few studies directly compare error rates across the stages of the medication-use process. In such a comparison, the method of error detection will

Suggested Citation:"Appendix C Medication Errors: Incidence Rates ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
×

substantially influence the estimate of error rates. Flynn and colleagues (2002) collected parallel data on 2,557 doses using direct observation, chart review, and voluntary incident reporting. Rates of error detected by the three methods across all study sites (including 24 hospitals and 12 nursing homes) were 17.8 percent, 0.1 percent, and 0.003 percent, respectively.

Three studies investigated error rates by stage of the medication-use process. Using a cohort design involving chart review and stimulated reporting, Gurwitz and colleagues (2000) detected most errors in the prescribing and monitoring stages. Among the 464 preventable ADEs identified in the study, errors occurred most often in the prescribing stage (315 errors, 68 percent of ADEs) and the monitoring stage (325 errors, 70 percent of ADEs). Errors were rare in the documentation/transcription, dispensing, and administration stages.

Similar results were found in a later study by the same research team using similar chart review methods (Gurwitz et al., 2005). Errors associated with the 338 preventable ADEs were more likely to occur at the prescribing (59 percent of ADEs) and monitoring (80 percent of ADEs) stages. Errors were less common at the dispensing and administration stages. Forty-six percent of preventable ADEs involved errors at two stages of the medication-use process, and 5 percent involved errors at three stages.

Handler and colleagues (2004) analyzed incident reports at one long-term care facility; they found an average of 4.7 reports per month, while residents averaged 11.2 medications per day. A process analysis indicated that the same stages of medication use occur in the nursing home and hospital settings. Consistent with hospital reporting, most incident reports in this study were filed by nurses; 68 percent of reported errors occurred at the administration stage, 20.4 percent at the dispensing stage, and 11.6 percent at both the administration and dispensing stages.

Incidence of ADEs in Nursing Homes

Retrospective Studies

Gurwitz and colleagues (1994) published a retrospective review of incident reports from one 703-bed academic nursing home for 1 year to identify adverse and unexpected events. After falls, medication-related events (n = 180) were most common, at 26 per 100 beds. Errors in dosing (72.2 percent of reports) were more common than adverse drug reactions (26.7 percent). A more recent study based on incident reports during 21 months at a single 126-bed long-term care facility identified 98 errors, but no denominator was used to compute error rates (Handler et al., 2004). Authors of both of these studies acknowledged that the findings under-

Suggested Citation:"Appendix C Medication Errors: Incidence Rates ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
×

represented the incidence of ADEs because of the limitations of the voluntary reporting of incidents.

Another retrospective review examined available medical charts for 175 admissions to one academic nursing home in the Veterans Administration system during an 18-month period, defining ADEs using a standardized protocol based on the Naranjo protocol (Gerety et al., 1993). A total of 201 ADEs occurred in 95 of the 175 admissions. On average, 1.2 ADEs occurred per resident (0.44 per patient month). Most ADEs were classified as minor, although 22.3 percent were rated serious, including one death. Limitations of this retrospective methodology for estimating error rates were potential misclassification of events (only 38 percent of ADEs were definitely or probably attributable to the medications) and the failure to identify the preventability of the ADEs (see Table C-8).

Prospective Studies

A prospective study of two Georgia nursing facilities over a 4-year period using monthly drug regimen review identified 444 adverse drug reactions (defined as unwanted consequences of drug therapy) in 74 percent of the 332 residents in the study (Cooper, 1999). There were 64 drug-associated hospitalizations in 52 of the 332 residents (15.7 percent).

Two studies from the same group of investigators used a prospective cohort design. The first (Gurwitz et al., 2000) examined the incidence and preventability of ADEs over a 12-month period in long-term residents of 18 nursing homes served by one pharmacy provider in Massachusetts. Data on ADEs (defined as an injury resulting from the use of a drug) for this cohort study were collected by chart review and simulated reporting, and prevent-ability was judged by two physician reviewers. The overall ADE rate was 1.89 per 100 resident months, with a preventable ADE rate of 0.96 per 100 resident months. More severe ADEs were more likely to be preventable (risk ratio = 2.1, p <0.001).

TABLE C-8 Nursing Homes: ADE Incidence

Study

ADEs per Patient-Month

ADEs per 100 Admissions

Proportion of ADEs Preventable

Gurwitz et al., 2000

0.02

Not given

51 percent (out of 546 ADEs in study)

Gurwitz et al., 2005

0.1

Not given

42 percent (out of 815 ADEs in study)

Gerety et al., 1993

0.44

115

Not given (201 ADEs in study)

Cooper, 1999

Not given

134

Not given (444 ADEs in study)

Suggested Citation:"Appendix C Medication Errors: Incidence Rates ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
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The same group (Gurwitz et al., 2005) used the above methodology enhanced by the continuous presence of pharmacist investigators and computerized alerts to identify the incidence of ADEs in two academic nursing homes in Connecticut and Ontario, Canada. The study found a rate of 9.6 ADEs per 100 resident-months, with a rate of 4.1 preventable ADEs per 100 resident-months. Overall, 42 percent of ADEs were deemed preventable, while 61 percent of serious, life-threatening, or fatal ADE were judged preventable. While the five-fold increase in ADE rates in this study was attributed to improved detection, the investigators concluded that these rates probably underestimated the ADE incidence since they were based on chart review rather than direct examination of the residents (see Table C-8).

If the findings of these two well-designed studies are applied to all U.S. nursing homes, between 24 and 120 ADEs occur annually in the average nursing home (bed size 105). Between 350,000 and 1.9 million ADEs occur each year among the 1.6 million U.S. nursing home residents, about 40–50 percent of which are preventable. Of the estimated 20,000–86,000 fatal or life-threatening ADEs, about 70–80 percent are preventable.

Adverse Drug Withdrawal Events (ADWEs)

While many investigators have noted that discontinuation of drugs can cause adverse events in nursing home patients (Gurwitz et al., 2000, 2005), only a few researchers have investigated these events separately from other ADEs. Gerety and colleagues introduced the concept of the ADWE into nursing home research in their retrospective chart review of nursing home admissions. Among 62 of 175 residents, 94 ADWEs occurred—a mean rate of 0.54 per resident and 0.32 per patient-month. A more recent study (Boockvar et al., 2004) evaluated adverse events due to drug discontinuations at the time of transfer of 87 residents between four nursing homes in New York and either of two academic hospitals. Medications were altered in 86 percent of the 122 hospital admissions, with a mean of 3.1 alterations per admission and 1.4 medication changes at discharge, excluding new medications. ADEs occurred in 20 percent of bidirectional transfers—50 percent involving medication discontinuation and 36 percent dosage changes. The time from change to ADE occurrence averaged 14 days, so most ADEs occurred on return to the nursing home. Although it was not determined whether the changes at transfer were accidental, this study addressed the problem that generated the 2005 Joint Commission on Accreditation of Healthcare Organizations (JCAHO) goal on medication regimen reconciliation.

Two other studies addressed ADWEs involving psychotropic medications, including benzodiazepines, with no evidence of negative effects on behavior or perception of carefully controlled tapered withdrawal (Cohen-

Suggested Citation:"Appendix C Medication Errors: Incidence Rates ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
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Mansfield et al., 1999) or more haphazard withdrawal or substitution (Zullich et al., 1993).

Underutilization of Medications

A few studies have considered underutilization of medications in long-term care, that is, failure to prescribe or administer medications for which there is an evidence base for reduction of morbidity and mortality and a best-practice designation (see Table C-9). Economic restrictions on medication acquisition could be a factor in the underutilization rates quoted below.

A retrospective study of 2,014 residents over age 65 from a stratified random sample of 193 assisted-living facilities in four U.S. states demonstrated that underutilization of medications was common (Sloane et al., 2004). Of 328 residents with congestive heart failure, 62 percent were not receiving an ACE inhibitor; of 172 subjects with a history of myocardial infarction, 60.5 percent were not receiving aspirin, and 76 percent were not receiving beta-blockers; of 435 residents with a history of stroke, 37.5 percent were not receiving an anticoagulant or antiplatelet product; and of 315 residents with osteoporosis, 61 percent were not receiving calcium supplementation, and 51 percent were not receiving any treatment.

In another retrospective review of the records of 2,587 nursing home residents, only 53 percent of ideal candidates with atrial fibrillation were receiving warfarin. The therapeutic international normalized ratio (INR) range was maintained only 51 percent of the time (McCormick et al., 2001).

In a Dutch study (van Dijk et al., 2003), the most common prescribing problem was omission of a gastroprotective drug, which occurred in 85 percent of residents taking nonsteroidal anti-inflammatory drugs (NSAIDs). Using judgments of an expert review panel, Ruths and colleagues identified underuse of beneficial therapy in 13 percent of residents in 23 nursing homes in Norway (Ruths et al., 2003).

Studies using the SAGE (Systematic Assessment of Geriatric drug use via Epidemiology) database that linked information from the Minimum Data Set (MDS) and nursing home drug utilization data showed that only 25 percent of 86,094 nursing home residents with congestive heart failure were prescribed an ACE inhibitor (Gambassi et al., 2000). Another study using SAGE data showed that only 55 percent of residents identified as depressed based on the MDS received antidepressants, and 35 percent of those received less than the manufacturer’s recommended dose (Brown et al., 2002), although underdosing may be appropriate for more frail elderly adults.

Inadequate pain management is a well-documented example of under-utilization of medication, with 45–80 percent of nursing home residents

Suggested Citation:"Appendix C Medication Errors: Incidence Rates ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
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TABLE C-9 Nursing Home Care: Prescription Errors of Omission

Residents 65+ with congestive heart failure

Percentage of residents receiving ACE inhibitors

38 (Sloane et al., 2004) (for resident 65+)

Residents with congestive heart failure

Percentage of residents prescribed ACE inhibitors

25 (Gambassi et al., 2000)

Residents 65+ with history of myocardial infarction

Percentage of residents receiving aspirin

40 (Sloane et al., 2004)

Residents 65+ with history of myocardial infarction

Percentage of residents receiving beta-blockers

24 (Sloane et al., 2004)

Residents 65+ with history of stroke

Percentage of residents receiving anticoagulant or antiplatelet product

63 (Sloane et al., 2004)

Residents 65+ with osteoporosis

Percentage of residents receiving calcium supplementation

39 (Sloane et al., 2004)

Residents 65+ with osteoporosis

Percentage of residents receiving any treatment

49 (Sloane et al., 2004)

Residents with atrial fibrillation

Percentage of residents receiving warfarin

53 (McCormick et al., 2001)

Residents taking nonsteroidal anti-flammatory drugs (NSAIDs)

Percentage of residents receiving gastroprotective drugs

15 (van Dijk et al., 2003)

Residents with depression

Percentage of residents receiving antidepressants

55 (Brown et al., 2002)

Residents with pain

Percentage of residents having unrelieved pain

45–80 (AGS, 2002)

Percentage of residents receiving no analgesics

~25 percent (Bernabei et al., 1998; Won et al., 1999, 2004)

Percentage of residents receiving optimal pain management

66 percent (Hutt et al., 2006).

having unrelieved pain (AGS, 2002). Cross-sectional studies using the SAGE database or MDS data have indicated that 26 percent of nursing home residents overall and 30 percent of those with a cancer diagnosis have daily pain, and approximately 25 percent of these individuals receive no analgesics (Bernabei et al., 1998; Won et al., 1999, 2004). Using a scale developed

Suggested Citation:"Appendix C Medication Errors: Incidence Rates ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
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to quantify the appropriateness of pain management in nursing homes, Hutt and colleagues (2006) calculated a mean score of 66 percent of optimal pain management in residents of 12 nursing homes in Colorado (Hutt et al., 2006). Fewer than half of the residents with predictably recurrent pain had prescriptions for scheduled pain medication, and only 40 percent with neuropathic pain were on an appropriate analgesic adjuvant.

Overuse of H2Blockers

Overutilization of medication, another indicator of inappropriate prescribing, was demonstrated in a retrospective chart review of the use of histamine-2 (H2) receptor blocker therapy among 711 residents in one academic nursing home (Gurwitz et al., 1992). H2 blocker therapy was used for unsubstantiated indications in 41 percent of the 110 residents receiving this category of drugs.

INCIDENCE OF MEDICATION ERRORS IN AMBULATORY CARE

For the purposes of this study, the committee examined medication error rates in six different settings within the ambulatory care domain: (1) the interface between care settings, for example, from hospital care to outpatient clinic; (2) the ambulatory clinic; (3) the community or mail order pharmacy; (4) the home care setting; (5) the self-care setting; and (6) the school setting.

Interface Between Care Settings

It is believed that medication errors and ADEs occur frequently in the interfaces between care settings, particularly after hospital discharge, yet the committee could find only two studies estimating error rates for such transitions (see Table C-10). In one study, a total of 42 (49 percent) patients who were discharged from the hospital and received continuing care from their primary care physicians experienced at least one medication error within 2 months of hospital discharge (Moore et al., 2003). In the other study, 45 (11 percent) of the 400 patients discharged from a general medicine service

TABLE C-10 Errors Across the Interfaces of Care

Hospital to clinic

Medication errors per patient—detection method

49 percent (Moore et al., 2003)—comparison of inpatient and outpatient records

Hospital to home

Preventable ADEs per patientdetection method

3 percent (Forster et al., 2005)—record review and patient interview

Suggested Citation:"Appendix C Medication Errors: Incidence Rates ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
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experienced an ADE: 32 patients had significant injuries, 6 had serious injuries, and 7 had life-threatening injuries; 27 percent of the ADEs were considered preventable, and 33 percent ameliorable (Forster et al., 2005).

The Ambulatory Clinic

Most studies on medication errors in ambulatory care have focused on prescribing errors (see Table C-11).

TABLE C-11 Ambulatory Clinic: Prescribing Errors

Prescription writing errors

Percentage of prescriptions containing at least one prescription writing error—detection method

21 (Shaughnessy and Nickel, 1989)—prescription review

Errors in an ambulatory hemodialysis unit

Percentage of patients with prescribing errorsdetection method

97.7 (Manley et al., 2003b)—chart review

Medication-related problems per patient per month—detection method

0.45 (Manley et al., 2003a)—pharmacist review of medication orders

Potential drug– drug interactions

Percentage of patients with two or more prescriptions with potential drugdrug interactions—detection method

6.2–6.7 (Solberg et al., 2004)—review of administration data

0.74 (Zhan et al., 2005)—review of administration data

Potential drug– disease interactions

Percentage of patients with two or more prescriptions with potential drugdisease interactionsdetection method

2.58 (Zhan et al., 2005)—review of administration data

Dispensing of samples

Percentage of labels with usual dosage not presentdetection method

12 (Dill and Generali, 2000)—review of samples

Dispensing of samples

Percentage of labels that referred user to enclosed prescribing information that was absent—detection method

17 (Dill and Generali, 2000)—review of samples

Lack of medication monitoring

Percentage of patients being treated with levothyroxine not receiving minimum monitoringdetection method

44 (Stelfox et al., 2004)—chart review

Documentation errors

Current medications per patient missing from patient record— detection method

0.37 (Wagner and Hogan, 1996)—review of patient record

0.89 (Bedell et al., 2000)—review of patient record

Documentation errors

Percentage of prescription renewals missing from patient record— detection method

15 (Ernst et al., 2001)—review of patient record

Suggested Citation:"Appendix C Medication Errors: Incidence Rates ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
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Prescription Writing Errors

In a retrospective review of 1,814 prescriptions written by 20 family medicine residents, Shaughnessy and Nickel (1989) found that 21 percent of the prescriptions contained at least one prescription writing error. The errors included omissions (6 percent), prescriptions written for nonprescription products (5 percent), incorrect doses or directions (3 percent), indecipherable quantity to be dispensed (3 percent), unfulfilled legal requirements (1 percent), and incomplete directions (1 percent).

Care Delivery in the Ambulatory Specialty Clinic

Although medication errors occur in ambulatory specialty clinics in association with chemotherapeutic agents, IV infusions, and hemodialysis, there is a lack of data on the incidence of these errors. Only three studies were found—two on hemodialyis and one on chemotherapy.

In one group of 133 ambulatory patients undergoing hemodialysis, the percentage of medication prescribing errors was 97.7 percent; the most frequent errors detected were prescribing medications without indication (30.9 percent), prescribing medications without laboratory-related monitoring (27.6 percent), and not prescribing a medication despite an indication for usage (17.5 percent) (Manley et al., 2003b).

A study carried out in August 2001 through May 2002 reviewed the medications of 133 patients in an ambulatory hemodialysis unit (Manley et al., 2003a). Over a 10-month period, a pharmacist reviewed 5,373 medication orders and identified 354 (6.6 percent) medication-related problems. Most common were medication dosing problems (33.5 percent), adverse drug reactions (20.7 percent), and an indication that was not currently being treated (13.5 percent). At the end of the study period, 0.45 medication-related problems per patient per month had been identified. Extrapolating these finding to the 246,000 U.S. hemodialysis patients would mean that almost 111,000 medication-related problems occur each month.

In a prospective cohort study at three outpatient chemotherapy units, 1,380 adults experienced 203 potential ADEs, none of which caused harm, and 226 children experienced 34 potential ADEs, again none causing harm (Gandhi et al., 2005). Overall, there was a medication error rate of 3 percent (306 out of 10,122 orders).

Potential Drug–Drug and Drug–Disease Interactions

Potential drug–drug interaction rates were found to range from 6.2 to 6.7 percent per year among users of a core group of commonly taken

Suggested Citation:"Appendix C Medication Errors: Incidence Rates ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
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medications. These estimates were derived from health plan administrative data (Solberg et al., 2004). A retrospective analysis of data from the 1995– 2000 National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey found inappropriate drug–drug combinations in 0.74 percent of visits involving two or more prescriptions and inappropriate drug–disease combinations in 2.58 percent of visits involving at least one prescription (Zhan et al., 2005).

Administering of Samples

Concerns about labeling have been researched for sample medications dispensed from the ambulatory care setting. In one study (Dill and Generali, 2000), involving 35 frequently used sample medications from 16 different manufacturers with nine drug classifications, information on the usual dosage was not present on 12 percent of the labels evaluated; 17 percent gave dosage and frequency; and 9 percent gave dosage, route, frequency, and duration. The remaining 62 percent referred the user to enclosed prescribing information, which in 27 percent of cases was not in fact enclosed.

Lack of Medication Monitoring

The committee identified only one study of medication monitoring in an ambulatory care setting. In a retrospective chart review of 400 outpatients being treated with levothyroxine at a large North American tertiary care hospital, only 56 percent of patients were found to have received minimum monitoring based on criteria derived from the literature and established through expert consensus (Stelfox et al., 2004). Those patients who received the recommended monitoring had fewer levothyroxine-related ADEs than those who did not (1 percent versus 6 percent).

Documentation Errors

Three studies have examined the rate of medication discrepancies in the outpatient medical record. A study in an outpatient geriatric center found that 0.37 of current medications per patient (43 medications/117 patients) were missing from the patient record, and 0.38 of medications per patient (44 medications/117 patients) were included in the record but were not currently being taken by the patient (Wagner and Hogan, 1996). About a third of these errors were judged to have been caused by patients who misreported a medication at a previous visit or changed (stopped, started, or dose-adjusted) a medication between visits. A study carried out in a private practice affiliated with an academic center, involving 312 patients from the practices of five cardiologists and two internists, found that 0.89

Suggested Citation:"Appendix C Medication Errors: Incidence Rates ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
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of current medications per patient (278 medications/312 patients) were missing from the patient record, and 0.51 of medications per patient (158 medications/312 patients) were included in the record but were not currently being taken by the patient (Bedell et al., 2000). In a family medicine outpatient clinic, pharmacists evaluated 950 prescription-renewal requests for 134 medications and found that 15 percent of prescriptions (147 out of 950) were for medications the patient was taking but were not recorded in the patient’s chart (Ernst et al., 2001).

The Community or Mail Order Pharmacy

A medication procurement error led to the inadvertent use of Bicillin C-R to treat syphilis in a Los Angeles clinic (CDC, 2005). In late 1998, the clinic pharmacy received a shipment of Bicillin C-R instead of Bicillin L-A. The pharmacy continued to order Bicillin C-R until March 2004. Other errors in the community pharmacy setting have been associated with telephoned prescriptions and medication dispensing (see Table C-12).

Prescription orders are frequently given by telephone. A study published in 1990 reported that that telephone prescriptions account for over 30 percent of all prescriptions (Spencer and Daugird, 1990). Although telephone prescription errors in the community pharmacy setting have raised concern about patient safety, the committee could only find one study addressing this topic. An observational study conducted in two community pharmacies over 11 days analyzed 813 telephone prescriptions (Camp et al., 2003). The investigators found that 12.4 percent of the telephone prescriptions contained an error. The most common types of errors included prescribing medication for the wrong patient, not providing the patient’s telephone number, prescribing the wrong strength, giving the wrong directions for use, and prescribing the wrong medication.

A study conducted in one hospital-based outpatient pharmacy found the rate of dispensing errors to be 12.5 percent (1,229/9,846 prescriptions), and 1.6 percent (155/9,846 prescriptions) of the prescriptions contained

TABLE C-12 Community Pharmacy: Errors

Telephoned prescription errorsf

Percentage of telephone prescriptions containing an error— detection method

12.4 (Camp et al., 2003)—direct observation

Dispensing errors

Percentage of prescription erroneously dispensed—detection method

1.7 (Flynn et al., 2003)—direct observation

3.4 (Buchanan et al., 1991)—direct observation

12.5 (Kistner et al., 1994)—audit of filled prescriptions

24 (Allan et al., 1995)—audit of filled prescriptions

Suggested Citation:"Appendix C Medication Errors: Incidence Rates ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
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errors that had the potential to cause serious harm (Kistner et al., 1994). Another study, conducted in 100 randomly selected community pharmacies, involved the analysis of 100 prescriptions. Allan and colleagues (1995) found 24 dispensing errors, 4 of which were clinically significant. In a cross-sectional, direct observational study at a high-volume outpatient pharmacy, the dispensing error rate was found to be 3.4 percent (Buchanan et al., 1991). In a more recent cross-sectional, direct observational study of 50 community pharmacies (encompassing chain, independent, and health system pharmacies) located in six cities across the United States, the investigators found that the overall dispensing accuracy rate for new and refill prescriptions was 98.3 percent (Flynn et al., 2003). They found 77 errors among the 4,481 prescriptions they analyzed. Of the 77 identified errors, 5 (6.5 percent) were judged to be clinically important. The medication error rate did not differ significantly by pharmacy type or city. This dispensing error rate indicates that there are approximately 4 errors per 250 prescriptions per pharmacy per day, translating to an estimated 51.5 million errors during the filling of 3 billion prescriptions each year.

One study of medication errors involving mail order pharmacy was found (see Table C-13). During September and October 2003, at a highly automated mail order pharmacy practice, the original prescription order was compared with the container contents and label (Teagarden et al., 2005). The overall dispensing error rate was 0.075 percent—16 dispensing errors among 21,252 prescriptions. Of these errors, 14 involved incomplete or incorrect directions on the final label, 1 was due to the entry of an incorrect quantity on the system record, and 1 was due to the omission of the drug on the system record. No errors were associated with the mechanical aspects of the dispensing process.

The Home Care Setting

Two studies have examined prescribing errors in the home care setting (see Table C-14). In an evaluation of 11,689 prescriptions taken by 2,193

TABLE C-13 Mail Order Pharmacy: Errors

Dispensing errors

Percentage of prescription erroneously dispensed—detection method

0.075 (Teagarden et al., 2005)—audit of filled prescriptions

TABLE C-14 Home Care Setting: Prescribing Errors

Inappropriate prescribing for elderlfy

Percentage of patients prescribed inappropriate medications

30 (Meredith et al., 2001)

40 (Golden et al., 1999)

Suggested Citation:"Appendix C Medication Errors: Incidence Rates ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
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homebound persons aged 60 and older, investigators found that 10 percent of these prescriptions were inappropriate (according to the Beers criteria) (Golden et al., 1999). Moreover, they found that 40 percent (871 out of 2,193 patients) of the subjects in the study had received at least one inappropriate prescription and that 10.5 percent (230 out of 2,193) had received two or more such prescriptions. A 2001 study analyzed the medication usage of 6,718 elderly home care patients and found that 30 percent had experienced potential medication errors when either the Home Health criteria (Brown et al., 1998) or the Beers criteria (Beers et al., 1992; Beers, 1997) were applied (Meredith et al., 2001).

In another study, self-reports of 101 home health care nurses from 12 agencies in six states showed that 78 percent of 1,467 patients who were in the nurses’ care were at increased risk for medication errors because they were taking five or more medications, although such errors actually occurred less frequently (Ellenbecker et al., 2004). The investigators also found that ADEs had occurred in approximately 5 percent of the reported patients.

The Self-Care Setting

Studies on medication errors in the self-care setting have been related largely to medication adherence (see Table C-15). There is a large body of literature on medication adherence, most of which relates to particular disease conditions. In an early study, medication adherence for prescribed medications was estimated at about 50 percent (Sackett and Snow, 1979).

In 2004, a meta-analysis of 569 studies reporting on adherence to medical treatments (328 relating to medications) was published (DiMatteo, 2004). For each study, the adherence rate, as defined by the study author(s), was extracted. The average adherence rate over all studies was 75.2 percent and over all medication studies was 79.4 percent. Adherence rates improved over time: the average rate for pre-1980 studies (80 studies) was 62.6 percent and for 1980–1998 studies (491 studies) was 76.3 percent (p <0.001). However, more recent studies investigating how adherence rates change over time and with frequency of daily dosing have found generally lower rates.

A study in which a medication event monitoring system was used to assess patients’ adherence to anticonvulsant medications found the average

TABLE C-15 Self-Care Setting: Adherence Rates

Adherence rates

Percentage medication adherence rate

80 (Corda et al., 2000)

76 (Cramer et al., 1989)

50 (Sackett and Snow, 1979)

Suggested Citation:"Appendix C Medication Errors: Incidence Rates ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
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adherence rate to be 76 percent during 3,428 patient-days observed (Cramer et al., 1989). The rate decreased, however, when the daily frequency increased: 87 percent for dosing once/day, 81 percent for dosing twice/day, 77 percent for dosing three times/day, and 39 percent for dosing four times/day.

Another study evaluated adherence to medication among health care professionals to estimate the expected upper limit of adherence among the general population. In a self-administered survey, physicians and nurses were asked about their use of prescribed medications for acute and chronic illnesses (Corda et al., 2000). Among the respondents, 301 physicians and nurses had been prescribed medications for acute and/or chronic illnesses within 2 years of the survey. Of 610 prescribed medications, 80 percent were taken as prescribed, with a 77 percent adherence rate for short-term medications and an 84 percent rate for long-term medications.

Sharing of prescription medications appears to be relatively common among children and adolescents (Daniel et al., 2003). In a mail survey of youths aged 9–18 (764 girls and 804 boys), 16 percent of the girls reported borrowing prescription medications from others and 15 percent sharing their prescription medications with someone else; the respective proportions among the boys were 12 and 8 percent. An adolescent obtaining a prescription medication through sharing does not receive the appropriate information about its actions and possible risks. Sharing of potentially teratogenic drugs is of particular concern.

Results similar to the above were obtained in a survey of 963 adult outpatients at a university general internal medicine practice (Shaheen et al., 2004). Of the participants, 16 percent (158/963) reported using someone else’s prescription medication. Of those who had been prescribed at least one medication in the past year, 17 percent (147/864) reported sharing their medication with someone else.

The School Setting

The committee found no studies on medication error rates in the school setting. Two studies have addressed this issue. In one study, 649 members of the National Association of School Nurses surveyed reported that 5.6 percent of school children were treated with medications in school; 3.3 percent of these children received medications for attention-deficit hyperactivity disorder (ADHD) (McCarthy et al., 2000). Almost all of the school nurses reported following written guidelines for administering medications, and 75.6 percent reported that they delegated medication administration to assertive unlicensed personnel (66.2 percent secretaries). About half (48.5 percent) reported errors in administering medication. Missing a dose was reported to be the most common error (79.9 percent).

Suggested Citation:"Appendix C Medication Errors: Incidence Rates ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
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TABLE C-16 Ambulatory Care: ADE Incidence

Study

Events per 100 Patients

ADEs per 100 Patient-Years

Proportion of ADEs Preventable

Gurwitz et al., 2003

Not given

5

28 percent (out of 1,523 ADEs in study)

Gandhi et al., 2000

18 drug complications

Not given

Not reported (394 drug complications in study)

Gandhi et al., 2003

27 ADEs

Not given

20 percent (out of 181 ADEs in study)

Incidence of ADEs During Ambulatory Care

The committee identified three studies on the rate of ADEs in ambulatory clinics (see Table C-16). In one study, using patient surveys and chart review, 394 (18 percent) patients reported a drug complication. Most of these complications were not noted in the medical chart, and it proved impossible to assess what proportion were preventable (Gandhi et al., 2000). A second study found that 162 (25 percent) of the 661 ambulatory care patients studied had experienced an ADE (Gandhi et al., 2003). Of the 181 ADEs found, 13 percent were serious, and 28 percent were ameliorable; 11 percent were attributed to the physician’s failure to respond to medication-related symptoms. A third study, involving Medicare patients, found an overall ADE rate of 50.1 per 1,000 patient-years and a preventable ADE rate of 13.8 per 1,000 patient-years (Gurwitz et al., 2003). Of the 38 percent of ADEs that were serious, 42.2 percent were preventable, and of the 62 percent of ADEs that were significant, 18.7 percent were preventable. The preventable ADEs occurred most often at the stages of prescribing (58.4 percent), monitoring (60.8 percent), and administration and patient adherence (21.1 percent).

INCIDENCE OF MEDICATION ERRORS IN PEDIATRIC CARE

It has become clear that the prescribing, dispensing, and administration of medications are associated with a substantial portion of the preventable medical errors that occur with children (Kaushal et al., 2001, 2004). Given the need to tailor all pediatric medication doses to body-size parameters (e.g., weight, body mass index), the fact that children are much less able than adults to double-check their own medications in any setting, and the wide range of appropriate doses for any medication based on the child’s size, children are uniquely vulnerable to medication errors. Accurate pediatric medication administration requires accurate weights; proper conversion of pounds to kilograms; the correct choice of appropriate preparations

Suggested Citation:"Appendix C Medication Errors: Incidence Rates ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
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and concentrations; and the ability to measure and administer doses properly, particularly for liquid medications. The ways children differ from adult patients can be summarized by the factors of developmental change, dependency on adults, different disease epidemiology, and demographic characteristics (Forrest et al., 2003). These factors predispose children to patient safety events resulting from, for example, young children needing to rely on adults for dose checking and having to take liquid medications rather than standard-sized pills.

Prescription and Selection of the Drug for the Patient

A number of studies have examined prescription and selection errors associated with medications for pediatric populations (see Table C-17). An inpatient study covering all types of medications carried out at two urban teaching hospitals reported a 4.2 percent error rate (454 physician ordering errors out of 10,778 orders), or 405 prescribing errors per 1,000 patients (Kaushal et al., 2001). Using a broader definition of medication error, a French study reported a higher error rate—24 percent (937 prescribing errors out of 3,943 orders) (Fontan et al., 2003). Also using a broader

TABLE C-17 Hospital Pediatric Care: Prescription and Selection Errors

Medication ordering errors

Percentage of prescriptions containing an error—detection method

4.2 (Kaushal et al., 2001)—chart review

24 (Fontan et al., 2003)—chart review

Medication ordering errors in pediatric ICU

Percentage of prescriptions containing an errordetection method

30 (Potts et al., 2004)—chart review

Preventable ADEs

Preventable ADEs per 1,000 admissions

0.6 (Hardmeier et al., 2004)

1.1 (Bates et al., 1995b)

1.4 (Nebeker et al., 2005)

Gentamicin prescribing in neonatal ICU

Percentage of prescriptions containing an errordetection method

13 (14/105) before computerized physician order entry (CPOE) (Cordero et al., 2004)—review of chart and medical record

0 (0/92) post CPOE (Cordero et al., 2004)—review of chart and medical record

Ten-fold prescribing errors intercepted before reaching the patient

Errors intercepted per 1,000 admissions—detection method

5.3 (Lesar, 2002b)—incident reports

Suggested Citation:"Appendix C Medication Errors: Incidence Rates ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
×

definition, a still higher rate of 30 percent was observed in a pediatric ICU (2,049 prescribing errors out of 6,803 orders) (Potts et al., 2004).

The French study cited above observed sharply differing error rates for handwritten and computerized prescribing. The study found a handwritten prescribing error rate of 88 percent (518 prescribing errors out of 589 orders) and a computerized prescribing error rate of 11 percent (419 errors out of 3,943 orders) (Fontan et al., 2003).

A more focused study in a neonatal ICU observed 14 Gentamicin prescription dosage errors in 105 very-low-birthweight infants (13 percent error rate) prior to the implementation of computerized physician order entry (CPOE) (Cordero et al., 2004). In 92 post-CPOE infants, no medication errors occurred. In another study in a neonatal ICU, 60 total parenteral nutrition errors were observed out of 557 total parenteral nutrition orders (11 percent error rate) (Lehmann et al., 2004).

Finally, another study evaluated ten-fold prescribing errors that were intercepted before reaching the patient. The occurrence of such errors in a 631-bed tertiary care teaching hospital was 0.53 per 100 pediatric admissions (Lesar, 2002b).

Medication Documentation

Three studies evaluated transcription/documentation errors for medications in hospital pediatric care (see Table C-18). In a study of two academic pediatric units, 85 documentation errors were found in 10,778 orders (0.8 percent) (Kaushal et al., 2001). In another study, 49 pediatric medication cardexes out of 540 (9 percent) were found to disagree in a major way (different dose, wrong medication, wrong frequency or duration, missing route) from the physician’s original medication order (Cable and Croft, 2004). In a third study, at the first transcription, 20.7 percent (41 out of 198) of nonchemotherapy prescriptions and 11.8 percent (16 out of 135) of chemotherapy prescriptions were transcribed incorrectly in a pediatric oncohematology unit (Pichon et al., 2002).

TABLE C-18 Hospital Pediatric Care: Documentation Errors

Medication documentation errors

Percentage of orders containing an error—detection method

0.8 (Kaushal et al., 2001)—chart review

9 (Cable and Croft, 2004)—chart review

Medication transcription errors in a pediatric oncohematology unit

Percentage of orders containing an error—detection method

20.7 nonchemotherapy prescriptions (Pichon et al., 2002)—chart review

11.8 chemotherapy prescriptions (Pichon et al., 2002)—chart review

Suggested Citation:"Appendix C Medication Errors: Incidence Rates ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
×

Preparation and Dispensing of the Drug

The committee identified only four studies addressing errors associated with the preparation and dispensing of medications in hospital pediatric care (see Table C-19). One study was based on chart reviews, which make it difficult to detect dispensing errors, particularly if errors are recognized and corrected before medication is given to the patient (Kaushal et al., 2001). This study estimated the rate of dispensing errors to be 0.05 errors per order written, or 5 dispensing errors per 1,000 patients.

Three other studies examined the proportion of dispensing errors among all reported medication errors. Estimates of this proportion vary widely: 4.5 percent for all types of medication in an inpatient setting (King et al., 2003), 9.3 percent for chemotherapy in an inpatient setting (France et al., 2004), and 58.9 percent for all types of medication in an ICU (Frey et al., 2002).

Administration of the Drug

Rates of drug administration errors have been reported in varying ways (see Table C-20). Administration errors were estimated to be 0.72 errors per 100 orders (or 7 per 100 admissions, or 19.8 per 1,000 patient-days) for all types of medication in an inpatient setting (Kaushal et al., 2001); 23

TABLE C-19 Hospital Pediatric Care: Preparation and Dispensing Errors

Error rates

Errors per 1,000 patientsdetection method

5 (Kaushal et al., 2001)—chart review

Proportion of dispensing errors among all medication errors

Percentage of reported errors related to dispensing—detection method

4.5 percent (inpatient setting) (King et al., 2003)—incident reports

9.3 percent (chemotherapy, inpatient setting) (France et al., 2004)— incident reports

58.9 percent (ICU) (Frey et al., 2002)—incident reports

TABLE C-20 Hospital Pediatric Care: Administration Errors

Error rates, inpatient unit

Errors per 100 orders—detection method

0.72 (Kaushal et al., 2001)—chart review

Error rates, inpatient unit

Errors per 100 admissions—detection method

7 (Kaushal et al., 2001)—chart review

Error rates, inpatient unit

Errors per 1,000 patient-days—detection method

19.8 (Kaushal et al., 2001)—chart review

Error rate, nephrology unit

Errors as a percentage of opportunities for error—detection method

23 (Fontan et al., 2003)—chart review

Suggested Citation:"Appendix C Medication Errors: Incidence Rates ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
×

percent of opportunities for administration errors in a pediatric nephrology ward (Fontan et al., 2003); 3.9 errors per 100 charts reviewed for all types of medication in an emergency department (Kozer et al., 2002); and 21.7 acetaminophen dosage errors per 100 patients receiving acetaminophen in an emergency department (Losek, 2004).

Monitoring of the Patient for Effect

Only one study reported on errors involving monitoring of the patient for effects (see Table C-21). Using chart review, this study estimated a rate of 4 errors per 1,000 patients (Kaushal et al., 2001).

Pediatric Care in the Ambulatory and Emergency Department Setting

The majority of pediatric medication error studies identified by the committee were focused on hospitalized patients. Three studies were focused on the ambulatory care setting and two studies on the emergency department setting. Of the three ambulatory care studies, all examined immunizations (see Table C-22). One study, conducted in the United States, defined invalid vaccine doses as doses given before the minimum recommended age, doses not given within the recommended spacing from the previous dose, doses given unnecessarily (defined as 1 year earlier than the required age), and live virus vaccine given too soon after a previous live virus vaccine. This study estimated 4 invalid doses per 100 immunizations given to children, or 36 percent of children being immunized receiving at

TABLE C-21 Hospital Pediatric Care: Monitoring Errors

Monitoring errors

Errors per 1,000 patients—detection method

4 (Kaushal et al., 2001)—chart review

TABLE C-22 Ambulatory Pediatric Care: Immunization Errors

Invalid doses

Invalid doses per every 100 immunizations—detection method

4 (Butte et al., 2001)—chart review

Overimmunized for at least one vaccine

Percentage of children overimmunized—detection method

21 (Feikema et al., 2000)—chart review from National Immunization Screenings

Vaccine doses reported to National Poison Registry

Doses reported per 1 million immunization doses—detection method

11 (Petridou et al., 2004)—incident reports

Suggested Citation:"Appendix C Medication Errors: Incidence Rates ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
×

least 1 invalid dose (Butte et al., 2001). A second study, also conducted in the United States, estimated 21 percent of children being overimmunized for at least one vaccine (Feikema et al., 2000). A third study reported on calls regarding vaccines to the National Poison Control Registry in Greece. The estimate of 11 vaccine errors per 1 million immunization doses likely represents significant underreporting since one would have to consider a vaccine dose to be a poisoning to call this registry (Petridou et al., 2004).

Of the two emergency department studies, one focused on global estimates of prescription and administration errors in this setting, and the other on medication errors with respect to antipyretics (see Table C-23). The first study estimated a rate of 100 prescribing errors per 1,000 patients and 39 administration errors per 1,000 patients (Kozer et al., 2002). The second study found that 22 percent of acetaminophen doses ordered were outside of the recommended 10–15 milligrams/kilogram dose (Losek, 2004).

Incidence of ADEs During Hospitalization

A prospective study analyzed 1,120 patients at two academic pediatric institutions during 1999 using chart, medication order sheet, and medication administration record review, as well as voluntary and solicited reports (Kaushal et al., 2001) (see Table C-24). Twenty-six ADEs were identified—

TABLE C-23 Emergency Department Pediatric Care: Prescription and Administration Errors

Prescribing errors

Errors per 1,000 patients—detection method

100 (Kozer et al., 2002)—chart review

Administration errors

Errors per 1,000 patients—detection method

39 (Kozer et al., 2002)—chart review

Acetaminophen doses ordered outside recommended range

Percentage of doses ordered outside recommended range—detection method

22 (Losek, 2004)—chart review

TABLE C-24 Hospital Care: Pediatric ADE Incidence During Hospitalization

Study

ADEs per 100 Admissions

ADEs per 1,000 Patient-Days

Proportion of ADEs Preventable

Kaushal et al., 2001

2.3

6.6

19 percent (out of 26 ADEs in the study)

Holdsworth et al., 2003

6

7.5

(76 ADEs in the study)

Suggested Citation:"Appendix C Medication Errors: Incidence Rates ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
×

2.3 per 100 admissions or 6.6 per 1,000 patient days; 19 percent of the ADEs were considered preventable.

A later prospective study analyzed 1,197 consecutive admissions (corresponding to 922 patients and 10,164 patient days) at a general pediatric unit and a pediatric ICU in a metropolitan medical center (Holdsworth et al., 2003). Seventy-six ADEs were identified—6 per 100 admissions or 7.5 per 1,000 patient days.

INCIDENCE OF MEDICATION ERRORS IN PSYCHIATRIC CARE

Many studies of medication errors associated with psychotropic medication were conducted as part of either larger general medical–surgical studies or ADE-reporting databases or were limited to geriatric populations in settings not restricted to psychiatric care, such as nursing homes and ambulatory clinics.

General Medical–Surgical Studies

An 18-month study in a tertiary care hospital used computerized monitoring to identify 701 ADEs, including 18 due to psychotropic drugs (2.4 percent) (Classen et al., 1991). A study using several active detection approaches, including daily chart review, among 4,031 medical–surgical inpatients found 247 ADEs (6.5 per 100 admissions) (Bates et al., 1993). Psychotropic medications represented 7 percent of all medication errors. A more recent study of hospitalized patients found that psychotropic drugs accounted for 0.41 percent of serious medication errors (Bates et al., 1998). After CPOE and a team intervention to prevent ADEs were implemented, this rate fell to 0.16 percent. A study using pharmacist detection of prescribing errors with potential for harm in a teaching hospital found that among 11,186 errors, 146 (1.3 percent) were associated with psychotropic medications (Lesar et al., 1997).

Geriatric Populations in Settings Not Restricted to Psychiatric Care

Older patients may be particularly vulnerable to the harmful effects of psychotropic medications (Monette et al., 1995). A 1-year study of 18 nursing homes reported that among 546 ADEs (1.89 per 100 resident-months), 193 (35 percent) were due to psychotropic medications (Gurwitz et al., 2000). A greater proportion of ADEs due to psychotropic medications (63 percent), as compared with all other drug classes (43 percent), was judged to be preventable.

One study found that psychotropic medications represented 23 percent of inappropriate medication orders prescribed in nursing homes (Beers et

Suggested Citation:"Appendix C Medication Errors: Incidence Rates ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
×

al., 1992). Two other studies found that older adults in ambulatory settings received even higher proportions of inappropriate psychotropic medications—27 percent (Aparasu and Fliginger, 1997) and 44 percent (Mort and Aparasu, 2000).

Psychiatric Hospitals

The committee identified two studies that examined the incidence of medication errors in a mental health setting (see Table C-25). The more recent of these retrospectively studied 31 state psychiatric inpatients over 2 months of care, for a total of 1,448 patient-days (Grasso et al., 2003). Nine errors were self-reported using the usual incident reporting process, whereas an independent multidisciplinary review team found 2,194 errors for the same 31 patients and episodes of care. There were 1,443 administration errors, accounting for more than half of the total (66 percent); 498 transcription errors (23 percent); 239 prescription errors (11 percent); and 14 dispensing errors (less than 1 percent). Nineteen percent of errors were rated as having a low risk of harm, 23 percent as having a moderate risk, and 58 percent as having a high risk.

The other study of ADEs included both inpatient and outpatient settings and focused on the frequency, severity, causes, and costs of ADEs in an integrated system of care that included medical and psychiatric patients (Senst et al., 2001). In this setting, medication errors were implicated in 13.6 percent of psychiatric readmissions, with medication nonadherence (considered part of the usual lexicon of medication errors) being implicated in 69 percent of hospitalizations. The rate of ADEs during psychiatric hospitalization was 4.2 per 100 admissions.

TABLE C-25 Psychiatric Care: Medication Errors

Prescribing errors

Errors per 1,000 patient-days—detection method

165 (Grasso et al., 2003)—chart review

Transcription errors

Errors per 1,000 patient-days—detection method

334 (Grasso et al., 2003)—chart review

Administration errors

Errors per 1,000 patient-days—detection method

997 (Grasso et al., 2003)—chart review

Dispensing errors

Errors per 1,000 patient-daysdetection method

10 (Grasso et al., 2003)—chart review

ADEs

Errors per 100 admissions—detection method

4.2 (Senst et al., 2001)—chart review

Suggested Citation:"Appendix C Medication Errors: Incidence Rates ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
×

The committee’s literature review yielded no reports focused specifically on medication errors in outpatient mental health settings, nor have there been medication error incidence studies in settings where psychologists have prescriptive authority. Finally, no studies were found on the incidence and characteristics of medication errors in substance abuse settings, including all settings where medical detoxification of individuals treated for alcohol, sedative hypnotic, or opiate withdrawal occurs. All of these are areas in which data are badly needed.

ERROR RATES: MUCH MORE NEEDS TO BE DONE

Where incidence rates of medication errors have been systematically measured, such errors have been found to be common and at unacceptably high levels. Errors in the administration of IV medications appear to be particularly prevalent. Reasonably well-researched stages of the medication-use process include prescribing, dispensing, and administering in hospitals; prescribing in ambulatory clinics; dispensing in community pharmacies; prescribing in the home care setting; medication adherence in the self-care setting; and inappropriate use of psychotropic drugs.

Where it is possible to compare the results of multiple studies, estimates of error rates vary widely. Much but not all of this variation can be explained by differences in definition and identification methods. Even when the definition of error is standardized and the same identification method is used, however, substantial variation in administration error rates by institution have been found (Barker et al., 2002). Taking account of this variability, the underlying error rates are unacceptably high.

Over the past decade, much scholarly activity and substantial government resources have been directed at determining the extent and scope of medication errors. Yet there are still broad aspects of the medication-use process for which we have little or no understanding of error rates. These include the selection and procurement of medications, monitoring of the effectiveness of medications in all care settings, medication use in schools, medication use in psychiatric care, and the use of over-the-counter and complementary and alternative medications.

The committee concludes that still greater effort is needed in all care settings to identify the incidence of medication errors—both to measure the extent and scope of such errors and to assess the impact of error prevention strategies.

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Gurwitz JH, Field TS, Judge J, Rochon P, Harrold LR, Cadoret C, Lee M, White K, LaPrino J, Mainard JF, DeFlorio M, Gavendo L, Auger J, Bates DW. 2005. The incidence of adverse drug events in two large academic long-term care facilities. The American Journal of Medicine 118(3):251–258.

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Suggested Citation:"Appendix C Medication Errors: Incidence Rates ." Institute of Medicine. 2007. Preventing Medication Errors. Washington, DC: The National Academies Press. doi: 10.17226/11623.
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In 1996 the Institute of Medicine launched the Quality Chasm Series, a series of reports focused on assessing and improving the nation’s quality of health care. Preventing Medication Errors is the newest volume in the series. Responding to the key messages in earlier volumes of the series—To Err Is Human (2000), Crossing the Quality Chasm (2001), and Patient Safety (2004)—this book sets forth an agenda for improving the safety of medication use. It begins by providing an overview of the system for drug development, regulation, distribution, and use. Preventing Medication Errors also examines the peer-reviewed literature on the incidence and the cost of medication errors and the effectiveness of error prevention strategies. Presenting data that will foster the reduction of medication errors, the book provides action agendas detailing the measures needed to improve the safety of medication use in both the short- and long-term. Patients, primary health care providers, health care organizations, purchasers of group health care, legislators, and those affiliated with providing medications and medication- related products and services will benefit from this guide to reducing medication errors.

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