Adverse drug events caused by serious medication administration errors. Issue 11 (12th July 2012)

• Record Type: Journal Article
• Authors: Kale, Abhivyakti; Keohane, Carol A; Maviglia, Saverio; Gandhi, Tejal K; Poon, Eric G
• Is Part Of: BMJ quality & safety. Volume 21:Issue 11(2012)
• Page Start: 933
• Page End: 938
• Publication Date: 2012-07-12
• Subjects: Adverse drug events -- patient safety -- clinical quality -- human factors -- medication errors; Medical care -- Quality control -- Periodicals; Health facilities -- Risk management -- Periodicals; Medical errors -- Prevention -- Periodicals; 362.106805
• DOI: 10.1136/bmjqs-2012-000946
• Languages: English
• ISSNs: 2044-5415

Abstract

Abstract : Objective: To determine how often serious or life-threatening medication administration errors with the potential to cause harm (potential adverse drug events) result in actual harm (adverse drug events (ADEs)) in the hospital setting. Design: Retrospective chart review of clinical events following observed medication administration errors. Background: Medication errors are common at the medication administration stage for inpatients. While many errors can cause harm, it is unclear exactly how often. Methods: In a previous study where 14 041 medication administrations were directly observed, 1271 medication administration errors were discovered, of which 133 had the potential to cause serious or life-threatening harm and were considered serious or life-threatening potential adverse drug events. As a follow-up, clinical reviewers conducted detailed chart review of serious or life-threatening potential ADEs to determine if they caused an ADE. Reviewers assessed severity of the ADE and attribution to the error. Results: Ten (7.5% (95% CI 6.98 to 8.01)) actual ADEs resulted from the 133 serious and life-threatening potential ADEs, of which 6 resulted in significant, three in serious, and one life threatening injury. Therefore 4 (3% (95% CI 2.12 to 3.6)) of serious or life threatening potential ADEs led to serious or life threatening ADEs. Half of the ADEs were caused by dosage or monitoring errors for anti-hypertensives. Conclusions: Unintercepted potential ADEs at the medication administration stage can cause serious patient harm. At hospitals where 6 million doses are administered per year, about 4000 preventable ADEs would be attributable to medication administration errors annually.