Medication errors observed in 36 health care facilities

Background: Medication errors are a national concern. Objective: To identify the prevalence of medication errors (doses administered differently than ordered). Design: A prospective cohort study. Setting: Hospitals accredited by the joint Commission on Accreditation of Healthcare Organizations, nonaccredited hospitals, and skilled nursing facilities in Georgia and Colorado. Participants: A stratified random sample of 36 institutions. Twenty-six declined, with random replacement. Medication doses given (or omitted) during at least 1 medication pass during a 1- to 4-day period by nurses on high medication-volume nursing units. The target sample was 50 day-shift doses per nursing unit or until all doses for that medication pass were administered. Methods: Medication errors were witnessed by observation, and verified by a research pharmacist (E.A.F.): Clinical significance was judged by an expert panel of physicians. Main Outcome Measure: Medication errors reaching patients. Results: In the 36 institutions, 19% of the doses (605/ 3216) were in error. The most frequent errors by category were wrong time (43%), omission (30%), wrong dose (17%), and unauthorized drug 4%. Seven percent of the errors were judged potential adverse drug events. There was no significant difference between error rates in the 3 settings (P=.82) or by size (P=.39). Error rates were higher in Colorado than in Georgia (P =.04). Conclusions: Medication errors were common (nearly 1 of every 5 doses in the typical hospital and skilled nursing facility). The percentage of errors rated potentially harmful was 7%, or more than 40 per day in a typical 300-patient facility. The problem of defective medication administration systems, although varied, is widespread.