Advertisement

Pharmacy World and Science

, Volume 27, Issue 2, pp 116–120 | Cite as

Medication errors when transferring elderly patients between primary health care and hospital care

  • Patrik MidlövEmail author
  • Anna Bergkvist
  • Åsa Bondesson
  • Tommy Eriksson
  • Peter Höglund
Article

Abstract

Objective: The aims were to evaluate the frequency and nature of errors in medication when patients are transferred between primary and secondary care.

Method: Elderly primary health care patients (> 65years) living in nursing homes or in their own homes with care provided by the community nursing system, had been admitted to one of two hospitals in southern Sweden, one university hospital and one local hospital. A total of 69 patient-transfers were included. Of these, 34 patients were admitted to hospital whereas 35 were discharged from hospital.

Main outcome measure: Percentage medication errors of all medications i.e. any error in the process of prescribing, dispensing, or administering a drug, and whether these had adverse consequences or not.

Results: There were 142 medication errors out of 758 transfers of medications. The patients in this study used on an average more than 10 drugs before, during and after hospital stay. On an average, there were two medication errors each time a patient was transferred between primary and secondary care. When patients were discharged from the hospital, the usage of a specific medication dispensing system constituted a significant risk for medication errors. The most common error when patients were transferred to the hospital was inadvertent withdrawal of drugs. When patients left the hospital the most common error was that drugs were erroneously added.

Conclusion: Medication errors are common when elderly patients are transferred between primary and secondary care. Improvement in documentation and transferring data about elderly patients’ medications could reduce these errors. The specific medication dispensing system that has been used in order to increase safety in medication dispensing does not seem to be a good instrument to reduce the number of errors in transferring data about medication.

Keywords

Drug related problems Drug use Elderly Integrated care Medication errors Pharmaceutical care Sweden 

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. Straand, J, Rokstad, KS. 1999Elderly patients in general practice: diagnoses, drugs and inappropriate prescriptionsA report from the More & Romsdal Prescription Study. Fam Pract.163808Google Scholar
  2. The National Board of Health and Welfare. [Diagnoses and drug prescriptions – a national survey] Stockholm: The National Board of Health and Welfare, 1999Google Scholar
  3. The National Board of Health and Welfare. [Drug use in nursing homes: special report 1999:1] Stockholm: The National Board of Health and Welfare, 1999Google Scholar
  4. Midlov, P, Bondesson, A, Eriksson, T, Petersson, J, Minthon, L, Hoglund, P. 2002Descriptive study and pharmacotherapeutic intervention in patients with epilepsy or Parkinson’s disease at nursing homes in southern SwedenEur J Clin Pharmacol.5790310CrossRefPubMedGoogle Scholar
  5. Field, TS, Gurwitz, JH, Avorn, J, McCormick, D, Jain, S, Eckler M., etal. 2001Risk factors for adverse drug events among nursing home residentsArch Intern Med.161162934CrossRefPubMedGoogle Scholar
  6. Col, N, Fanale, JE, Kronholm, P. 1990The role of medication noncompliance and adverse drug reactions in hospitalizations of the elderlyArch Intern Med.1508415CrossRefPubMedGoogle Scholar
  7. Seymour RM, Routledge PA. Important drug–drug interactions in the elderly. Drugs Aging 1998; 12(6): 485–94Google Scholar
  8. Veehof, L, Stewart, R, Haaijer-Ruskamp, F, Jong, BM. 2000The development of polypharmacyA longitudinal study. Fam Pract.172617Google Scholar
  9. Lazarou, J, Pomeranz, BH, Corey, PN. 1998Incidence of adverse drug reactions in hospitalized patients: a meta-analysis of prospective studiesJAMA.27912005CrossRefPubMedGoogle Scholar
  10. McDonnell, PJ, Jacobs, MR. 2002Hospital admissions resulting from preventable adverse drug reactionsAnn Pharmacother.3613316CrossRefPubMedGoogle Scholar
  11. Gurwitz, JH, Field, TS, Avorn, J, McCormick, D, Jain, S, Eckler M., etal. 2000Incidence and preventability of adverse drug events in nursing homesAm J Med.1098794CrossRefPubMedGoogle Scholar
  12. Bergman, U, Wiholm, BE. 1981Drug-related problems causing admission to a medical clinicEur J Clin Pharmacol.20193200CrossRefPubMedGoogle Scholar
  13. Hallas, J, Harvald, B, Worm, J, Beck-Nielsen, J, Gram, LF, Grodum E., etal. 1993Drug related hospital admissionsResults from an intervention program. Eur J Clin Pharmacol.45199203Google Scholar
  14. Mjorndal, T, Boman, MD, Hagg, S, Backstrom, M, Wiholm, BE, Wahlin A., etal. 2002Adverse drug reactions as a cause for admissions to a department of internal medicinePharmacoepidemiol Drug Saf.116572CrossRefPubMedGoogle Scholar
  15. Roughead, EE, Gilbert, AL, Primrose, JG, Sansom, LN. 1998Drug-related hospital admissions: a review of Australian studies published 1988–1996Med J Aust.1684058PubMedGoogle Scholar
  16. Lesar, TS, Briceland, LL, Delcoure, K, Parmalee, JC, Masta-Gornic, V, Pohl, H. 1990Medication prescribing errors in a teaching hospitalJama.263232934CrossRefPubMedGoogle Scholar
  17. Myhr, R, Kimsas, A. 1999[Medication errors when transferring within health care services]Tidsskr Nor Laegeforen.119108791PubMedGoogle Scholar
  18. Leape, LL. 1995Preventing adverse drug eventsAm J Health Syst Pharm.5237982PubMedGoogle Scholar
  19. WHO Collaborating Centre for Drug Statistics Methodology. Anatomical Therapeutic Chemical (ATC) Classification Index. Oslo: World Health Organisation, 2000. http://www.whocc.no/atcddd (accessed 12 May 2004)Google Scholar
  20. Kam, WJ, Meyboomde Jong, B, Tromp, TF, Moorman, PW, Lei, J. 2001Effects of electronic communication between the GP and the pharmacistThe quality of medication data on admission and after discharge. Fam Pract.186059Google Scholar
  21. Dean, B, Schachter, M, Vincent, C, Barber, N. 2002Causes of prescribing errors in hospital inpatients: a prospective studyLancet.35913738CrossRefPubMedGoogle Scholar
  22. Barker, KN, Flynn, EA, Pepper, GA, Bates, DW, Mikeal, RL. 2002Medication errors observed in 36 health care facilitiesArch Intern Med.16218971903CrossRefPubMedGoogle Scholar
  23. Paquette-Lamontagne, N, McLean, WM, Besse, L, Cusson, J. 2001Evaluation of a new integrated discharge prescription formAnn Pharmacother .359538CrossRefPubMedGoogle Scholar

Copyright information

© Springer 2005

Authors and Affiliations

  • Patrik Midlöv
    • 1
    Email author
  • Anna Bergkvist
    • 2
  • Åsa Bondesson
    • 3
  • Tommy Eriksson
    • 4
  • Peter Höglund
    • 3
  1. 1.Department of Clinical PharmacologyTåbelund Primary Health Care Centre, Lund University HospitalEslöv, LundSweden
  2. 2.Hospital PharmacyKristianstad Central HospitalKristianstadSweden
  3. 3.Department of Clinical PharmacologyLund University HospitalLundSweden
  4. 4.Hospital PharmacyLund University HospitalLundSweden

Personalised recommendations