Prescribing errors during hospital inpatient care: factors influencing identification by pharmacists
First Online: 24 September 2009 Received: 11 May 2009 Accepted: 14 September 2009 DOI:
Cite this article as: Tully, M.P. & Buchan, I.E. Pharm World Sci (2009) 31: 682. doi:10.1007/s11096-009-9332-x Abstract Objective: To investigate the prevalence of prescribing errors identified by pharmacists in hospital inpatients and the factors influencing error identification rates by pharmacists throughout hospital admission. Setting: 880-bed university teaching hospital in North-west England. Methods: Data about prescribing errors identified by pharmacists (median: 9 (range 4–17) collecting data per day) when conducting routine work were prospectively recorded on 38 randomly selected days over 18 months. Main outcome measures: Proportion of new medication orders in which an error was identified; predictors of error identification rate, adjusted for workload and seniority of pharmacist, day of week, type of ward or stage of patient admission. Results: 33,012 new medication orders were reviewed for 5,199 patients; 3,455 errors (in 10.5% of orders) were identified for 2,040 patients (39.2%; median 1, range 1–12). Most were problem orders (1,456, 42.1%) or potentially significant errors (1,748, 50.6%); 197 (5.7%) were potentially serious; 1.6% ( n = 54) were potentially severe or fatal. Errors were 41% (CI: 28–56%) more likely to be identified at patient’s admission than at other times, independent of confounders. Workload was the strongest predictor of error identification rates, with 40% (33–46%) less errors identified on the busiest days than at other times. Errors identified fell by 1.9% (1.5–2.3%) for every additional chart checked, independent of confounders. Conclusions: Pharmacists routinely identify errors but increasing workload may reduce identification rates. Where resources are limited, they may be better spent on identifying and addressing errors immediately after admission to hospital. Keywords Hospital admission Hospital pharmacist Medicines reconciliation Prescribing errors Workload, United Kingdom References
Dean B, Schachter M, Vincent C, Barber N. Prescribing errors in hospital inpatients: their incidence and clinical significance. Qual Saf Health Care. 2002;11(4):340–4.
Lesar TS, Lomaestro BM, Pohl H. Medication-prescribing errors in a teaching hospital. A 9-year experience. Arch Intern Med. 1997;157:1569–76.
Bobb A, Gleason K, Husch M, Feinglass J, Yarnold PR, Noskin GA. The epidemiology of prescribing errors: the potential impact of computerized prescriber order entry. Arch Intern Med. 2004;164(7):785–92.
Blum KV, Abel SR, Urbanski CJ. Medication error prevention by pharmacists. Am J Hosp Pharm. 1988;45:1902–3.
Folli HL, Poole RL, Benitz WE. Medication error prevention by clinical pharmacists in two children’s hospitals. Pediatrics. 1987;79:718–22.
Hawkey CJ, Hodgson S, Norman A, Danseshmend TK, Garner ST. Effect of reactive pharmacy intervention on quality of hospital prescribing. BMJ. 1990;300:986–90.
Audit Commission. A spoonful of sugar—improving medicines management in hospitals. London: Audit Commission; 2001.
National Institute for Health and Clinical Excellence, National Patient Safety Agency. Technical patient safety solutions for medicines reconciliation on admission of adults to hospital. London: National Institute for Health and Clinical Excellence; 2007.
Slee A, Farrar K, Hughes D, Constable S. Optimising medical treatment—how pharmacist-acquired medication histories have a positive impact on patient care. Pharm J. 2006;277:737–9.
Lesar TS, Briceland L, Delcoure K, Parmalee JC, Masta-Gornick V, Pohl H. Medication-prescribing errors in a teaching hospital. JAMA. 1990;263:2329–34.
Dean B, Barber N, Schachter M. What is a prescribing error? Qual Health Care. 2000;9:232–7.
Dean Franklin B, Vincent C, Schachter M, Barber N. The incidence of prescribing errors in hospital inpatients: an overview of the research methods. Drug Saf. 2005;28(10):891–900.
Donyai P, O’Grady K, Jacklin A, Barber N, Franklin BD. The effects of electronic prescribing on the quality of prescribing. Br J Clin Pharmacol. 2008;65(2):230–7.
Lewis P, Dornan T, Taylor D, Tully MP, Wass V, Ashcroft DM. Systematic review of the prevalence, incidence and nature of prescribing errors in hospital inpatients. Drug Saf. 2009;32:379–89.
Jha AK, DesRoches CM, Campbell EG, Donelan K, Rao SR, Ferris TG, et al. Use of electronic health records in U.S. hospitals. N Engl J Med. 2009;360(16):1628–38.
Bates DW, Cullen DJ, Laird N, Petersen LA, Small SD, Servi D, et al. Incidence of adverse drug events and potential adverse drug events. JAMA. 1995;274:29–34.
Phansalkar S, Hoffman JM, Nebeker JR, Hurdle JF. Pharmacists versus nonpharmacists in adverse drug event detection: a meta-analysis and systematic review. Am J Health Syst Pharm. 2007;64(8):842–9.
Tam VC, Knowles SR, Cornish PL, Fine N, Marchesano R, Etchells EE. Frequency, type and clinical importance of medication history errors at admission to hospital: a systematic review. CMAJ. 2005;173(5):510–5.
Vira T, Colquhoun M, Etchells E. Reconcilable differences: correcting medication errors at hospital admission and discharge. Qual Saf Health Care. 2006;15(2):122–6.
Midlov P, Bergkvist A, Bondesson A, Eriksson T, Hoglund P. Medication errors when transferring elderly patients between primary health care and hospital care. Pharm World Sci. 2005;27:116–20.
World Health Organisation. Action on patient safety—high 5 s. World alliance for patient safety. 2009. URL:
. Accessed 8 Jul 2009.
National Prescribing Centre. Medicines reconciliation: a guide to implementation. Liverpool: National Prescribing Centre; 2007.
Institute for Healthcare Improvement. Protecting 5 million lives from harm. Institute for Healthcare Improvement. 2009. URL:
. Accessed 8 Jul 2009.
Joint Commission on Accreditation of Healthcare Organizations. Hospitals’ national patient safety goals. Joint Commission on Accreditation of Healthcare Organizations. 2009. URL:
Accessed 8 Jul 2009.
Healthcare Commission. The best medicine. The management of medicines in acute and specialist trusts. London: Commission for Healthcare Audit and Inspection; 2007.
Barber N, Blackett A, Batty R. Does a high workload decrease ward pharmacists’ clinical monitoring? Int J Pharm Pract. 1993;2(3):152–5.
Rupp MT, DeYoung M, Schondelmeyer SW. Prescribing problems and pharmacist interventions in community practice. Med Care. 1992;30:926–40.
Hawksworth GM, Corlett AJ, Wright DJ, Chrystyn H. Clinical pharmacy interventions by community pharmacists during the dispensing process. Br J Clin Pharmacol. 1999;47:695–700.
Tissot E, Cornette C, Limat S, Mourand JL, Becker M, Etievent JP, et al. Observational study of potential risk factors of medication administration errors. Pharm World Sci. 2003;25(6):264–8.
Davydov L, Caliendo G, Mehl B, Smith LG. Investigation of correlation between house-staff work hours and prescribing errors. Am J Health Syst Pharm. 2004;61(11):1130–4.
Coombes ID, Stowasser DA, Coombes JA, Mitchell C. Why do interns make prescribing errors? A qualitative study. Med J Aust. 2008;188(2):89–94.
Dean B, Schachter M, Vincent C, Barber N. Causes of prescribing errors in hospital inpatients—a prospective study. Lancet. 2002;359:1373–8.
Nichols P, Copeland TS, Craib IA, Hopkins P, Bruce DG. Learning from error: identifying contributory causes of medication errors in an Australian hospital. Med J Aust. 2008;188(5):276–9.
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