More near misses than medical errors
Only 3% of medication errors at U.S. hospitals result in a patient being harmed or dying, but there are far more "near misses," according to information released by the U.S. Pharmacopeia (USP).
The newly released USP report indicates that nearly a quarter (23%) of the medication errors occurring at hospitals in the study did not reach the patient. In 55% of cases, an error reached the patient but did not cause harm.
A broad definition of error
The report summarizes results of a yearlong study of data submitted to MedMARx, a national data repository created to allow hospitals to anonymously report and track medication errors in a standardized format. The analysis is based on 6,224 medication errors reported by 56 hospitals.
USP, a nonprofit drug data and standards-setting body, is the first to examine actual reported medication errors since the Institute of Medi-cine (IOM) drew national attention to the problem in 1999 in a landmark report on medical errors. To assess the whole picture, USP adopted a broad definition of error, which encompasses the so-called "near misses."
The majority of medication errors (40%) involved administering medication, vs. the 11% that were due to prescribing errors. Forty-five percent of the errors reported to the database involved multiple causes. More than half of the time, hospitals ascribed errors to a combination of "performance deficit" (meaning that the reason for the error could not be explained) and other factors. Contributing factors in the "performance deficit" category included distractions and workload increase.
A copy of the MedMARx data is available at USP’s Web site, www.usp.org/medmarx.
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