An Overview of Medication Mistakes in Hospital

In 2002, a group of medical professionals led by Dr. Kenneth N. Barker, director and researcher from Auburn University, performed a study concerning medication mistakes that occurred in hospitals. The findings were published in the September issue of “Archives of Internal Medicine.” During a four-day period, researchers assessed the medications administered or omitted. During the study, a licensed nurse or pharmacist accompanied and observed hospital nurses as each employee prepared and provided patients with medications. The researchers later compared observations with patients’ charts.

Medication Error Statistics

Out of 3,216 doses of medication administered, an error took place 19 percent of the time. Medications were given at the wrong time during 43 percent of the events. Patients were not provided a prescribed medication 30 percent of the time. Nurses prepared and administered the wrong dosage in 17 percent of the situations. In 4 percent of the administration events, patients received an unauthorized drug. The panel of physicians further found that the mistakes posed a potential threat to patients 7 percent of the time. This percentage equates to more than 40 occurrences every day at any 300-bed medical facility.

Complexity Part of the Problem

“BMJ Quality and Safety” published an article discussing human error in a number of industries that included the medical profession. According to the research cited, complexity plays a major role in the number of medication errors committed. Complexity is most commonly perceived as the number of steps required to complete a task. However, complexity also occurs with the degree of difficulty or the duration of tasks. Intensive care units, for example, exhibited a higher degree of medication mistakes compared with non-critical care units of hospitals. Similarly, the longer a patient remains in the hospital, the higher the risk that individual would become the victim of a medication mistake.

Strategies for Reducing Medication Errors

Minimizing complexity means reducing the number of steps required to complete a preparation and the administration of a medication. Improving product design may minimize the number of steps involved. Critical care units requiring healthcare professionals with advanced levels of education to manage and track patient care is thought to minimize the difficulty experienced by staff. Reducing the number of days patients spend in the hospital decreases the likelihood of error.

Patients now wear identification devices with bar codes that must match prescribed medications and treatments. Located in hospital pharmacies, computerized order-entry systems have the capability of receiving physician prescriptions directly, which eliminates possible errors from misinterpreting written orders. The technology also poses questions and emits alert messages that require pharmacist intervention to ensure the accuracy of an order.

Sources:
http://www.webmd.com/mental-health/news/20020910/medication-errors-rampant-in-hospitals
http://qualitysafety.bmj.com/content/12/5/359.full?sid=04e2b4b6-69af-4983-8087-28d6c46b7c8f#sec-7