Journal of General Internal Medicine

, Volume 10, Issue 4, pp 199–205 | Cite as

Relationship between medication errors and adverse drug events

  • David W. Bates
  • Deborah L Boyle
  • Martha B. Vander Vliet
  • James Schneider
  • Lucian Leape
Original Articles

Abstract

OBJECTIVE: To evaluate the frequency of medication errors using a multidisciplinary approach, to classify these errors by type, and to determine how often medication errors are associated with adverse drug events (ADEs) and potential ADEs.

DESIGN: Medication errors were detected using self-report by pharmacists, nurse review of all patient charts, and review of all medication sheets. Incidents that were thought to represent ADEs or potential ADEs were identified through spontaneous reporting from nursing or pharmacy personnel, solicited reporting from nurses, and daily chart review by the study nurse. Incidents were subsequently classified by two independent reviewers as ADEs or potential ADEs.

SETTING: Three medical units at an urban tertiary care hospital.

PATIENTS: A cohort of 379 consecutive admissions during a 51-day period (1,704 patient-days).

INTERVENTION: None.

MEASUREMENTS AND MAIN RESULTS: Over the study period, 10,070 medication orders were written, and 530 medications errors were identified (5.3 errors/100 orders), for a mean of 0.3 medication errors per patient-day, or 1.4 per admission. Of the medication errors, 53% involved at least one missing dose of a medication; 15% involved other dose errors, 8% frequency errors, and 5% route errors. During the same period, 25 ADEs and 35 potential ADEs were found. Of the 25 ADEs, five (20%) were associated with medication errors; all were judged preventable. Thus, five of 530 medication errors (0.9%) resulted in ADEs. Physician computer order entry could have prevented 84% of non-missing dose medication errors, 86% of potential ADEs, and 60% of preventable ADEs.

CONCLUSIONS: Medication errors are common, although relatively few result in ADEs. However, those that do are preventable, many through physician computer order entry.

Key words

medication error adverse drug event computer order entry 

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. 1.
    Brennan TA, Leape LL, Laird N, et al. Incidence of adverse events and negligence in hospitalized patients: results from the Harvard Medical Practice Study I. N Engl J Med. 1991;324:370–6.PubMedCrossRefGoogle Scholar
  2. 2.
    Steel K, Gertman PM, Crescenzi C, Anderson J. Iatrogenic illness on a general medical service at a university hospital. N Engl J Med. 1981;304:638–42.PubMedCrossRefGoogle Scholar
  3. 3.
    Grymonpre RE, Mitenko PA, Sitar DS, et al. Drug-associated hospital admissions in older medical patients. J Am Geriatr Soc. 1988;36:1092–8.PubMedGoogle Scholar
  4. 4.
    Classen DC, Pestotnik SL, Evans RS, Burke JP. Computerized surveillance of adverse drug events in hospital patients. JAMA. 1991;266:2847–51.PubMedCrossRefGoogle Scholar
  5. 5.
    Keith MR, Bellanger-McCleery RA, Fuchs JE Jr. Multidisciplinary program for detecting and evaluating adverse drug reactions. Am J Hosp Pharm. 1989;46:1809–12.PubMedGoogle Scholar
  6. 6.
    Edlavitch SA. Adverse drug event reporting. Improving the low US reporting rates. Arch Intern Med. 1988;148:1499–503.PubMedCrossRefGoogle Scholar
  7. 7.
    Bates DW, Leape LL, Petrycki S. Incidence and preventability of adverse drug events in hospitalized adults. J Gen Intern Med. 1993;8:289–94.PubMedGoogle Scholar
  8. 8.
    Leape, LL. Brennan TA, Laird NM, et al. The nature of adverse events in hospitalized patients: results from the Harvard Medical Practice Study II. N Engl J Med. 1991;324:377–84.PubMedCrossRefGoogle Scholar
  9. 9.
    Melmon KL. Preventable drug reactions—causes and cures. Sem Med Beth Israel Hosp. 1971;284:1361–7.Google Scholar
  10. 10.
    Lesar TS, Briceland LL, Delcoure K, Parmalle JC, Masta-Gornic V, Pohl H. Medication prescribing errors in a teaching hospital. JAMA. 1990;263:2329–34.PubMedCrossRefGoogle Scholar
  11. 11.
    Folli HL, Poole RL, Benitz WE, Russo JC. Medication error prevention by clinical pharmacists in two children’s hospitals. Pediatrics 1987;79:718–22.PubMedGoogle Scholar
  12. 12.
    Beers MH, Ouslander JG, Fingold SF, et al. Inappropriate medication prescribing in skilled-nursing facilities. Ann Intern Med 1992;117:684–9.PubMedGoogle Scholar
  13. 13.
    Neville RG, Robertson F, Livingstone S, Crombie IK. A classification of prescription errors. J R Coll Gen Pract. 1989;39:110–2.PubMedGoogle Scholar
  14. 14.
    ASHP guidelines on preventing medication errors in hospitals. Am J Hosp Pharm. 1993;50:305–14.Google Scholar
  15. 15.
    Rheinstein PH, McGinnis TJ. Medication errors. Am Fam Physician. 1992;45:2720–2.PubMedGoogle Scholar
  16. 16.
    Zellmer WA. Medication error versus medication misadventure—what’s in a name? Am J Hosp Pharm. 1993;50:315–8.PubMedGoogle Scholar
  17. 17.
    Cohen MR, Davis NM. Dispensing the wrong medication. Am Pharm. 1992;NS32:28–9, 32.PubMedGoogle Scholar
  18. 18.
    Schroeder CG, Pierpaoli PG. Direct order entry by physicians in a computerized hospital information system. Am J Hosp Pharm. 1986;43:355–9.PubMedGoogle Scholar
  19. 19.
    Tierney WM, Miller ME, Overhage JM, McDonald CJ. Physician in-patient order writing on microcomputer workstations. Effects on resource utilization. JAMA. 1993;269:379–83.PubMedCrossRefGoogle Scholar
  20. 20.
    Dubous RW, Brook RH. Preventable deaths: who, how often, and why. Ann Intern Med. 1988;190:582–9.Google Scholar
  21. 21.
    Feinstein AR. Clinical Epidemiology: The Architecture of Clinical Research. Philadelphia: W.B. Saunders, 1985.Google Scholar
  22. 22.
    Fleiss JL. Statistical Methods for Rates and Proportions. New York: John Wiley and Sons, 1981.Google Scholar
  23. 23.
    SAS Institute Inc. Release 6.03. Cary, NC: SAS, 1988.Google Scholar
  24. 24.
    Blum KV, Abel SR, Urbanski CJ, Pierce JM. Medication error prevention by pharmacists. Am J Hosp Pharm. 1988;45:1902–3.PubMedGoogle Scholar
  25. 25.
    Raju TN, Kecskes S, Thornton JP, Perry M, Feldman S. Medication errors in neonatal and pediatric intensive-care units. Lancet. 1989;2:374–6.PubMedCrossRefGoogle Scholar
  26. 26.
    Shaughnesy AF, Nickel RO. Prescription-writing patterns and errors in a family medicine residency program. J Fam Pract. 1989;29:290–5.Google Scholar
  27. 27.
    Anastasio GD, Sigmon JL Jr. Prescription-writing errors [letter; comment]. J Fam Pract. 1990;30:108.PubMedGoogle Scholar
  28. 28.
    Anastasio GD, White TR, Fries JC. Computerized Prescription Inventory Program for the Education of Residents (PIPER). J Fam Pract. 1986;23:598–600.PubMedGoogle Scholar
  29. 29.
    Betz RP, Levy HB. An interdisciplinary method of classifying and monitoring medication errors. Am J Hosp Pharm. 1985;42:1724–32.PubMedGoogle Scholar
  30. 30.
    Simborg DW, Derewicz HJ. A highly automated hospital medication system. Five years’ experience and evaluation. Ann Intern Med 1975;83:324–6.Google Scholar
  31. 31.
    Hawkey CJ, Hodgson S, Norman A, Daneshmend TK, Garner ST. Effect of reactive pharmacy intervention on quality of hospital prescribing. BMJ. 1990;300:986–90.PubMedGoogle Scholar
  32. 32.
    Means BJ, Derewicz HJ, Lamy PP. Medication errors in a multidose and a computer-based unit dose drug distribution system. Am J Hosp Pharm. 1975;32:186–91.PubMedGoogle Scholar
  33. 33.
    Pang F, Granat JA. Missing medications associated with centralized unit dose dispensing. Am J Hosp Pharm. 1975;32:1121–3.PubMedGoogle Scholar
  34. 34.
    Kitrenos JG, Glue K, Stotter ML. Analysis of missing medication episodes in a unit dose system. Hosp Pharm. 1979;14:642, 648, 652–3.PubMedGoogle Scholar
  35. 35.
    Grabowski B. Missing medications in a unit-dose system: quality assurance. Hosp Pharm. 1987;22:679–80.PubMedGoogle Scholar
  36. 36.
    Churchill WW, Gavin TJ, Souney PF, Stachowski JS. Source of missing doses in a decentralized unit dose system: a quality assurance review. Hosp Pharm. 1988;23:453–6.PubMedGoogle Scholar
  37. 37.
    Evans RS, Classen DC, Stevens LE, et al. Using a hospital information system to assess the effects of adverse drug events. Proc Annu Symp Comput Appl Med Care. 1994;17:161–6.Google Scholar
  38. 38.
    Massaro TA. Introducing physician order entry at a major academic medical center: I. Impact on organization culture and behavior. Acad Med. 1993;68:20–5.PubMedCrossRefGoogle Scholar
  39. 39.
    Massaro TA. Introducing physician order entry at a major academic medical center: II. Impact on medical education. Acad. Med. 1993;68:25–30.Google Scholar
  40. 40.
    Ellinoy BJ, Bilroy G. Another step toward computerized order entry. Am J Hosp Pharm. 1990;47:2460–1.PubMedGoogle Scholar
  41. 41.
    Kawahara NE, Jordan FM. Influencing prescribing behavior by adapting computerized order-entry pathways. Am J Hosp Pharm. 1989;45:1798–801.Google Scholar
  42. 42.
    Poikonen J. Computerized order entry: hospital versus pharmacy-based systems. Am J Hosp Pharm. 1990;47:2461–2.PubMedGoogle Scholar
  43. 43.
    Preece JF, Ashford JR, Hunt RG. Writing all prescriptions by computer. J R Coll Gen Pract. 1984;34:655–7.PubMedGoogle Scholar
  44. 44.
    Donald JB. On line prescribing by computer. BMJ. 1986:292; 937–9.PubMedCrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 1995

Authors and Affiliations

  • David W. Bates
    • 1
  • Deborah L Boyle
  • Martha B. Vander Vliet
  • James Schneider
  • Lucian Leape
  1. 1.Division of General Medicine, Department of MedicineBrigham and Women’s HospitalBoston

Personalised recommendations