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

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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.

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  • J Straand KS. Rokstad (1999) ArticleTitleElderly patients in general practice: diagnoses, drugs and inappropriate prescriptions A report from the More & Romsdal Prescription Study. Fam Pract. 16 IssueID4 380–8

    Google Scholar 

  • The National Board of Health and Welfare. [Diagnoses and drug prescriptions – a national survey] Stockholm: The National Board of Health and Welfare, 1999

  • The National Board of Health and Welfare. [Drug use in nursing homes: special report 1999:1] Stockholm: The National Board of Health and Welfare, 1999

  • P Midlov A Bondesson T Eriksson J Petersson L Minthon P. Hoglund (2002) ArticleTitleDescriptive study and pharmacotherapeutic intervention in patients with epilepsy or Parkinson’s disease at nursing homes in southern Sweden Eur J Clin Pharmacol. 57 IssueID12 903–10 Occurrence Handle10.1007/s00228-001-0408-3 Occurrence Handle11936711

    Article  PubMed  Google Scholar 

  • TS Field JH Gurwitz J Avorn D McCormick S Jain etal. Eckler M. (2001) ArticleTitleRisk factors for adverse drug events among nursing home residents Arch Intern Med. 161 IssueID13 1629–34 Occurrence Handle10.1001/archinte.161.13.1629 Occurrence Handle1:STN:280:DC%2BD3MvhsFalsg%3D%3D Occurrence Handle11434795

    Article  CAS  PubMed  Google Scholar 

  • N Col JE Fanale P. Kronholm (1990) ArticleTitleThe role of medication noncompliance and adverse drug reactions in hospitalizations of the elderly Arch Intern Med. 150 IssueID4 841–5 Occurrence Handle10.1001/archinte.150.4.841 Occurrence Handle1:STN:280:By%2BB38rpt1E%3D Occurrence Handle2327844

    Article  CAS  PubMed  Google Scholar 

  • Seymour RM, Routledge PA. Important drug–drug interactions in the elderly. Drugs Aging 1998; 12(6): 485–94

    Google Scholar 

  • L Veehof R Stewart F Haaijer-Ruskamp BM. Jong (2000) ArticleTitleThe development of polypharmacy A longitudinal study. Fam Pract. 17 IssueID3 261–7 Occurrence Handle1:STN:280:DC%2BD3czpsFKksg%3D%3D

    CAS  Google Scholar 

  • J Lazarou BH Pomeranz PN. Corey (1998) ArticleTitleIncidence of adverse drug reactions in hospitalized patients: a meta-analysis of prospective studies JAMA. 279 IssueID15 1200–5 Occurrence Handle10.1001/jama.279.15.1200 Occurrence Handle1:STN:280:DyaK1c3hsFSnsQ%3D%3D Occurrence Handle9555760

    Article  CAS  PubMed  Google Scholar 

  • PJ McDonnell MR. Jacobs (2002) ArticleTitleHospital admissions resulting from preventable adverse drug reactions Ann Pharmacother. 36 IssueID9 1331–6 Occurrence Handle10.1345/aph.1A333 Occurrence Handle12196047

    Article  PubMed  Google Scholar 

  • JH Gurwitz TS Field J Avorn D McCormick S Jain etal. Eckler M. (2000) ArticleTitleIncidence and preventability of adverse drug events in nursing homes Am J Med. 109 IssueID2 87–94 Occurrence Handle10.1016/S0002-9343(00)00451-4 Occurrence Handle1:STN:280:DC%2BD3cvosV2nsA%3D%3D Occurrence Handle10967148

    Article  CAS  PubMed  Google Scholar 

  • U Bergman BE. Wiholm (1981) ArticleTitleDrug-related problems causing admission to a medical clinic Eur J Clin Pharmacol. 20 IssueID3 193–200 Occurrence Handle10.1007/BF00544597 Occurrence Handle1:STN:280:Bi2D38jktFE%3D Occurrence Handle7286037

    Article  CAS  PubMed  Google Scholar 

  • J Hallas B Harvald J Worm J Beck-Nielsen LF Gram etal. Grodum E. (1993) ArticleTitleDrug related hospital admissions Results from an intervention program. Eur J Clin Pharmacol. 45 IssueID3 199–203 Occurrence Handle1:STN:280:ByuC3c3jt1M%3D

    CAS  Google Scholar 

  • T Mjorndal MD Boman S Hagg M Backstrom BE Wiholm etal. Wahlin A. (2002) ArticleTitleAdverse drug reactions as a cause for admissions to a department of internal medicine Pharmacoepidemiol Drug Saf. 11 IssueID1 65–72 Occurrence Handle10.1002/pds.667 Occurrence Handle11998554

    Article  PubMed  Google Scholar 

  • EE Roughead AL Gilbert JG Primrose LN. Sansom (1998) ArticleTitleDrug-related hospital admissions: a review of Australian studies published 1988–1996 Med J Aust. 168 IssueID8 405–8 Occurrence Handle1:STN:280:DyaK1c3lslejuw%3D%3D Occurrence Handle9594953

    CAS  PubMed  Google Scholar 

  • TS Lesar LL Briceland K Delcoure JC Parmalee V Masta-Gornic H. Pohl (1990) ArticleTitleMedication prescribing errors in a teaching hospital Jama. 263 IssueID17 2329–34 Occurrence Handle10.1001/jama.263.17.2329 Occurrence Handle1:STN:280:By%2BB3MbivFE%3D Occurrence Handle2325234

    Article  CAS  PubMed  Google Scholar 

  • R Myhr A. Kimsas (1999) ArticleTitle[Medication errors when transferring within health care services] Tidsskr Nor Laegeforen. 119 IssueID8 1087–91 Occurrence Handle1:STN:280:DyaK1M3ksFSqsQ%3D%3D Occurrence Handle10228409

    CAS  PubMed  Google Scholar 

  • LL. Leape (1995) ArticleTitlePreventing adverse drug events Am J Health Syst Pharm. 52 IssueID4 379–82 Occurrence Handle1:STN:280:ByqB2sjlvVU%3D Occurrence Handle7757863

    CAS  PubMed  Google Scholar 

  • WHO Collaborating Centre for Drug Statistics Methodology. Anatomical Therapeutic Chemical (ATC) Classification Index. Oslo: World Health Organisation, 2000. (accessed 12 May 2004)

  • WJ Kam Particlevan der B Meyboomde Jong TF Tromp PW Moorman J. Lei Particlevan der (2001) ArticleTitleEffects of electronic communication between the GP and the pharmacist The quality of medication data on admission and after discharge. Fam Pract. 18 IssueID6 605–9

    Google Scholar 

  • B Dean M Schachter C Vincent N. Barber (2002) ArticleTitleCauses of prescribing errors in hospital inpatients: a prospective study Lancet. 359 IssueID9315 1373–8 Occurrence Handle10.1016/S0140-6736(02)08350-2 Occurrence Handle11978334

    Article  PubMed  Google Scholar 

  • KN Barker EA Flynn GA Pepper DW Bates RL. Mikeal (2002) ArticleTitleMedication errors observed in 36 health care facilities Arch Intern Med. 162 IssueID16 1897–1903 Occurrence Handle10.1001/archinte.162.16.1897 Occurrence Handle12196090

    Article  PubMed  Google Scholar 

  • N Paquette-Lamontagne WM McLean L Besse J. Cusson (2001) ArticleTitleEvaluation of a new integrated discharge prescription form Ann Pharmacother . 35 IssueID7–8 953–8 Occurrence Handle10.1345/aph.10244 Occurrence Handle1:STN:280:DC%2BD38%2FislCquw%3D%3D Occurrence Handle11485150

    Article  CAS  PubMed  Google Scholar 

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Correspondence to Patrik Midlöv.

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Midlöv, P., Bergkvist, A., Bondesson, Å. et al. Medication errors when transferring elderly patients between primary health care and hospital care. Pharm World Sci 27, 116–120 (2005).

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