Background and objective
Medication errors are common in healthcare settings. Previous poison-center studies have evaluated medication errors, but not specifically iatrogenic or in-hospital errors. The purpose of this study was to describe errors attributed to healthcare professionals or occurring in a healthcare facility reported to poison centers.
This was a retrospective study of medication errors reported to the US National Poison Data System from 2000 through 2017. Inclusion criteria were reason for exposure coded “unintentional, therapeutic error”, error scenario of health professional/iatrogenic error, or the location of exposure was in a healthcare facility. Variables assessed for each case included age, medication class, error scenario, medical outcome, and day of week and time case initiated. Descriptive statistics were performed.
There were 99,431 cases included. Median age was 20 years (interquartile range: 3–53), with ages ranging from 1 day to 108 years; 50.0% of cases were female. The most frequently reported medication categories were antimicrobials (13.6%), followed by analgesics (10.1%), then sedatives/hypnotics (8.9%), although the classes of drugs varied by age group. The most common error scenarios were “wrong medication taken or given,” “other incorrect dose,” and “incorrect dosing route,” although these differed by age group with more “other incorrect dose” reported in 0–5 years and “wrong medication taken or given” predominating in the other age groups. Serious effects (death and major effect) occurred at a higher frequency in the 65 + years age group than in all other age groups. The time of day with the most cases was 7–9 pm, with the lowest around 3–5 am. Fewer cases were reported on weekends than during the other days of the week.
This study provides a more detailed evaluation of iatrogenic and in-hospital errors reported to poison centers and their related scenarios. Prevention efforts should continue to focus on reducing the incidence of errors with an emphasis on reducing the most frequent errors.
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Billstein-Leber M, Carrillo CJD, Cassano AT, et al. ASHP guidelines on preventing medication errors in hospitals. Am J Health Syst Pharm. 2018;75:1493–517.
Campbell PJ, Patel M, Martin JR, et al. Systematic review and meta-analysis of community pharmacy error rates in the USA: 1993–2015. BMJ Open Qual. 2018;7:e000193–8.
Tran T, Taylor SE, Hardidge A, et al. The prevalence and nature of medication errors and adverse events related to preadmission medications when patients are admitted to an orthopedic inpatient unit: an observational study. Ann Pharmacother. 2018;43:106002801880247–9.
Korb-Savoldelli V, Boussadi A, Durieux P, et al. Prevalence of computerized physician order entry systems–related medication prescription errors: a systematic review. Int J Med Inform (Elsevier). 2018;111:112–22.
Institute of Medicine (US) Committee on quality of health care in America; Kohn LT, Corrigan JM, Donaldson MS, editors.. To err is human: building a safer health system. Washington, DC: National Academies Press; 2000. pp. 1–312.
Vaida AJ. The Institute for Safe Medication Practices and Poison Control Centers: collaborating to prevent medication errors and unintentional poisonings. J Med Toxicol. 2015;11:262–4.
Gummin DD, Mowry JB, Spyker DA, et al. 2017 annual report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 35th annual report. Clin Toxicol (Phila). 2018;56:1213–415.
Hodges NL, Spiller HA, Casavant MJ, et al. Non-health care facility medication errors resulting in serious medical outcomes. Clin Toxicol (Phila). 2018;56:43–50.
Kamboj AK, Spiller HA, Casavant MJ, et al. Non-health care facility cardiovascular medication errors in the United States. Ann Pharmacother. 2017;51:825–33.
Brophy TJ, Spiller HA, Casavant MJ, et al. Medication errors reported to U.S. Poison Control Centers, 2000–2012. Clin Toxicol (Phila). 2014;52:880–8.
Smith MD, Spiller HA, Casavant MJ, et al. Out-of-hospital medication errors among young children in the United States, 2002–2012. Pediatrics. 2014;134:867–76.
American Association of Poison Control Centers (AAPCC). National Poison Data System (NPDS): NPDS coding users’ manual. Version 4.0. Alexandria: American Association of Poison Control Centers; 2019, pp. 1–111.
Gummin DD, Mowry JB, Spyker DA, et al. 2016 annual report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 34th annual report. Clin Toxicol (Phila). 2017;55:1072–254.
Aseeri MA. The impact of a pediatric antibiotic standard dosing table on dosing errors. J Pediatr Pharmacol Ther. 2013;18:220–6.
University of Michigan College of Pharmacy. State-wide initiative to standardize the compounding of oral liquids in pediatrics. http://www.mipedscompounds.org. Accessed 10 Dec 2019.
Gandhi TK, Weingart SN, Borus J, et al. Adverse drug events in ambulatory care. N Engl J Med. 2003;348:1556–64.
Olson KR, Erdman AR, Woolf AD, et al. Calcium channel blocker ingestion: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila). 2005;43:797–822.
Wax P, Erdman A, Chyka P, et al. β-Blocker ingestion: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila). 2005;43:131–46.
Hoeve CE, van Haren A, Sturkenboom MCJM, et al. Spontaneous reports of vaccination errors in the European regulatory database EudraVigilance: a descriptive study. Vaccine. 2018;36:7956–64.
Hibbs BF, Moro PL, Lewis P, et al. Vaccination errors reported to the Vaccine Adverse Event Reporting System, (VAERS) United States, 2000–2013. Vaccine. 2015;33:3171–8.
Bundy DG, Shore AD, Morlock LL, et al. Pediatric vaccination errors: application of the “5 rights” framework to a national error reporting database. Vaccine. 2009;27:3890–6.
Magid S, Forrer C, Shaha S. Duplicate orders: an unintended consequence of computerized provider/physician order entry (CPOE) implementation: analysis and mitigation strategies. Appl Clin Inform. 2012;3:377–91.
Truitt E, Thompson R, Blazey-Martin D, et al. Effect of the implementation of barcode technology and an electronic medication administration record on adverse drug events. Hosp Pharm. 2016;51:474–83.
Koppel R, Wetterneck T, Telles JL, et al. Workarounds to barcode medication administration systems: their occurrences, causes, and threats to patient safety. J Am Med Inform Assoc. 2008;15:408–23.
Leonard JB, Klein-Schwartz W. The others: characterizing “other” therapeutic errors reported to a poison center. Clin Toxicol (Phila). 2019;47:1–5.
Hayes BD, Klein-Schwartz W. Consistency between coded poison center data and fatality abstract narratives for therapeutic error deaths in older adults. Clin Toxicol (Phila). 2010;48:68–71.
Correia MS, Whitehead E, Cantrell FL, et al. A 10-year review of single medication double-dose ingestions in the nation’s largest poison control system. Clin Toxicol (Phila). 2018;3:1–5.
Miller AD, Piro CC, Rudisill CN, et al. Nighttime and weekend medication error rates in an inpatient pediatric population. Ann Pharmacother. 2010;44:1739–46.
This study was presented in poster format at the 2018 American Society of Health-System Pharmacists Midyear Clinical Meeting. The American Association of Poison Control Centers (AAPCC) maintains the National Poison Data System (NPDS), which houses de-identified case records of self-reported information collected from callers during exposure management and poison information calls managed by the country’s poison control centers (PCCs). NPDS data do not reflect the entire universe of exposure to a particular substance as additional exposure may go unreported to PCCs; accordingly, NPDS data should not be construed to represent the complete incidence of US exposures to any substance(s). Exposures do not necessarily represent a poisoning or overdose and the AAPCC is not able to completely verify the accuracy of every report. Findings based on NPDS data do not necessarily reflect the opinions of the AAPCC.
No funding was secured for this study. The authors have no financial relationships relevant to this article to disclose.
This study was determined to be “Not-Human Subject Research” by the Institutional Review Board.
Conflict of interest
James B. Leonard, Chelsea McFadden, Agnes Ann Feemster, and Wendy Klein-Schwartz have no conflicts of interest relevant to this article to disclose.
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Leonard, J.B., McFadden, C., Feemster, A.A. et al. Analysis of iatrogenic and in-hospital medication errors reported to United States poison centers: a retrospective observational study. Drugs Ther Perspect 36, 190–201 (2020). https://doi.org/10.1007/s40267-020-00723-z