Dose, quantity errors top list of medication problems
July 1, 2002 2 minutes read
Dose, quantity errors top list of medication problems
The top-three causes of reported medication are omission errors, improper dose/quantity, and unauthorized drugs, according to the MedMARx 2000 Report, released recently by the U.S. Pharmacopeia (USP). The high number of omission errors indicates that when drug therapy is needed, patients may not, in fact, be getting the medications they need, the report says.
Additionally, when a drug is given, it may be at the wrong dose, or worse yet, the wrong drug entirely.
The report findings also note that with medication errors that caused harm, actions taken were more frequently documented in 2000 (60%) as compared to 38% in 1999, perhaps signaling that hospitals are doing a better job of documenting medication error information.
MedMARx is an Internet-accessible and anonymous reporting program used by hospitals to track and trend medication errors. The de-identified data submitted by participating hospitals are stored in a central national database at USP and are analyzed for educational and research programs.
Diane D. Cousins, RPh, USP vice president for practitioner and product experience, says the trends indicate that while progress in reporting errors is being made, the same types of errors are occurring again and again.
"This tells us that there are deeper, more systemic causes for these errors," she says. "The systems need to change in order to reduce errors."
The 1999 MedMARx report analyzed 6,224 medication-error reports from 56 facilities. USP analysis indicated that most reported errors (97%) did not result in patient harm. In the MedMARx 2000 Data Report, the number of reporting facilities increased threefold to 184, with a sevenfold increase in the number of reports, totaling 41,296.
In both the 1999 and the 2000 reports, the most frequently identified causes of error were performance deficit and procedure/protocol not followed. Computer entry and transcription inaccurate/omitted became two of the five most frequent reasons for medication errors. Both the 1999 and 2000 reports indicate that distractions, workload increase, and inexperienced staff are the most common contributing factors to medication errors. In the 2000 report, staffing issues became one of the five most frequently cited reasons for medication errors — accounting for 33% of records (an increase of 6% compared to the 1999 data).
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