Analgesic-Related Medication Errors Reported to US Poison Control Centers. Issue 12 (23rd November 2017)

• Record Type: Journal Article
• Authors: Eluri, Madhulika; Spiller, Henry A; Casavant, Marcel J; Chounthirath, Thitphalak; Conner, Kristen A; Smith, Gary A
• Is Part Of: Pain medicine. Volume 19:Issue 12(2018)
• Page Start: 2357
• Page End: 2370
• Publication Date: 2017-11-23
• Subjects: Analgesic -- Acetaminophen -- Opioid -- Ibuprofen -- Poisoning -- Poison Control Center; Pain -- Periodicals; Pain -- Treatment -- Periodicals; Analgesics -- Periodicals; Pain -- Periodicals; Pain Management -- Periodicals; Douleur -- Périodiques; Douleur -- Traitement -- Périodiques; Analgésiques -- Périodiques; Analgésique; Soulagement de la douleur; Périodique électronique (Descripteur de forme); Ressource Internet (Descripteur de forme); 616.047205
• DOI: 10.1093/pm/pnx272
• Languages: English
• ISSNs: 1526-2375

Abstract

Abstract: Objective: This study investigates the characteristics and trends of medication errors involving analgesic medications. Design and Methods: A retrospective analysis was conducted of analgesic-related medication errors reported to the National Poison Data System (NPDS) from 2000 through 2012. Results: From 2000 through 2012, the NPDS received 533, 763 reports of analgesic-related medication errors, averaging 41, 059 medication errors annually. Overall, the rate of analgesic-related medication errors reported to the NPDS increased significantly by 82.6% from 2000 to 2009, followed by a 5.7% nonsignificant decrease from 2009 to 2012. Among the analgesic categories, rates of both acetaminophen-related and opioid-related medication errors reported to the NPDS increased during 2000–2009, but the opioid error rate leveled off during 2009–2012, while the acetaminophen error rate decreased by 17.9%. Analgesic-related medication errors involved nonsteroidal anti-inflammatory drugs (37.0%), acetaminophen (35.5%), and opioids (23.2%). Children five years or younger accounted for 38.8% of analgesics-related medication errors. Most (90.2%) analgesic-related medication errors were managed on-site, rather than at a health care facility; 1.6% were admitted to a hospital, and 1.5% experienced serious medical outcomes, including 145 deaths. The most common type of medication error was inadvertently taking/given the medication twice (26.6%). Conclusion: Analgesic-related medication errors are common, and although most do not result in clinical consequences, they can have serious adverse outcomes. Initiatives associated with the decrease in acetaminophen-related medication errors among young children merit additional research and potential replication as a model combining government policy and multisectoral collaboration.