Drug Safety

, Volume 32, Issue 5, pp 379–389

Prevalence, Incidence and Nature of Prescribing Errors in Hospital Inpatients

A Systematic Review
  • Penny J. Lewis
  • Tim Dornan
  • David Taylor
  • Mary P. Tully
  • Val Wass
  • Darren M. Ashcroft
Review Article

Abstract

Prescribing errors affect patient safety throughout hospital practice. Previous reviews of studies have often targeted specific populations or settings, or did not adopt a systematic approach to reviewing the literature. Therefore, we set out to systematically review the prevalence, incidence and nature of prescribing errors in hospital inpatients. MEDLINE, EMBASE, CINAHL and International Pharmaceutical Abstracts (all from 1985 to October 2007) were searched for studies of prescriptions for adult or child hospital inpatients giving enough data to calculate an error rate. Electronic prescriptions and errors for single diseases, routes of administration or types of prescribing error were excluded, as were non-English language publications. Median error rate (interquartile range [IQR]) was 7% (2–14%) of medication orders, 52 (8–227) errors per 100 admissions and 24 (6–212) errors per 1000 patient days. Most studies (84%) were conducted in single hospitals and originated from the US or UK (72%). Most errors were intercepted and reported before they caused harm, although two studies reported adverse drug events. Errors were most common with antimicrobials and more common in adults (median 18% of orders [ten studies, IQR 7–25%]) than children (median 4% [six studies, IQR 2–17%]). Incorrect dosage was the most common error.

Overall, it is clear that prescribing errors are a common occurrence, affecting 7% of medication orders, 2% of patient days and 50% of hospital admissions. However, the reported rates of prescribing errors varied greatly and this could be partly explained by variations in the definition of a prescribing error, the methods used to collect error data and the setting of the study. Furthermore, a lack of standardization between severity scales prevented any comparison of error severity across studies. Future research should address the wide disparity of data-collection methods and definitions that bedevils comparison of error rates or meta-analysis of different studies.

Supplementary material

40264_2012_32050379_MOESM1_ESM.pdf (197 kb)
Supplementary material, approximately 202 KB.

References

  1. 1.
    Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I. N Engl J Med 1991 Feb;324(6): 370–6PubMedCrossRefGoogle Scholar
  2. 2.
    Classen DC, Pestotnik SL, Evans RS, et al. Adverse drug events in hospitalized patients: excess length of stay, extra costs, and attributable mortality. JAMA 1997 Jan; 277(4): 301–6PubMedCrossRefGoogle Scholar
  3. 3.
    Phillips DP, Christenfeld N, Glynn LM. Increase in US medication-error deaths between 1983 and 1993. Lancet 1998 Feb; 351(9103): 643–4PubMedCrossRefGoogle Scholar
  4. 4.
    Bates DW, Spell N, Cullen DJ, et al. The costs of adverse drug events in hospitalized patients. Adverse Drug Events Prevention Study Group. JAMA 1997 Jan; 277(4): 307–11PubMedCrossRefGoogle Scholar
  5. 5.
    National Patient Safety Agency. Safety in doses: medication safety incidents in the NHS report [online]. Available from URL: http://www.npsa.nhs.uk/nrls/alerts-and-directives/directives-guidance/safety-in-doses/ [Accessed 2009 Mar 5]
  6. 6.
    Winterstein AG, Johns TE, Rosenberg EI, et al. Nature and causes of clinically significant medication errors in a 387 tertiary care hospital. Am J Health Syst Pharm 2004 Sep; 61(18): 1908–16PubMedGoogle Scholar
  7. 7.
    Lesar TS, Briceland L, Stein DS. Factors related to errors in medication prescribing. JAMA 1997 Jan; 277(4): 312–7PubMedCrossRefGoogle Scholar
  8. 8.
    Morrill GB, Barreuther C. Screening discharge prescriptions. Am J Hosp Pharm 1988 Sep; 45(9): 1904–5PubMedGoogle Scholar
  9. 9.
    Fowlie F, Benniw M, Jardine G, et al. Evaluation of an electronic prescribing and administration system in a British hospital [abstract]. Pharm J 2000 Sep; 265(7114): R16Google Scholar
  10. 10.
    Gethins B. Wise up to medication errors. Pharm Pract 1996 Oct; 6: 323–8Google Scholar
  11. 11.
    Wong IC, Ghaleb MA, Franklin BD, et al. Incidence and nature of dosing errors in paediatric medications: a systematic review. Drug Saf 2004; 27(9): 661–70PubMedCrossRefGoogle Scholar
  12. 12.
    Ghaleb MA, Barber N, Franklin BD, et al. Systematic review of medication errors in pediatric patients. Ann Pharmacother 2006 Oct; 40(10): 1766–76PubMedCrossRefGoogle Scholar
  13. 13.
    Maidment ID, Lelliott P, Paton C. Medication errors in mental healthcare: a systematic review. Qual Saf Health Care 2006 Dec; 15(6): 409–13PubMedCrossRefGoogle Scholar
  14. 14.
    Franklin BD, Vincent C, Schachter M, et al. The incidence of prescribing errors in hospital inpatients: an overview of the research methods. Drug Saf 2005; 28(10): 891–900CrossRefGoogle Scholar
  15. 15.
    Allan EL, Barker KN. Fundamentals of medication error research. Am J Hosp Pharm 1990 Mar; 47(3): 555–71PubMedGoogle Scholar
  16. 16.
    Thomsen LA, Winterstein AG, Sondergaard B, et al. Systematic review of the incidence and characteristics of preventable adverse drug events in ambulatory care. Ann Pharmacother 2007 Sep; 41(9): 1411–26PubMedCrossRefGoogle Scholar
  17. 17.
    Anderson JG, Jay SJ, Anderson M, et al. Evaluating the potential effectiveness of using computerized information systems to prevent adverse drug events. Proc AMIA Annu Fall Symp 1997; 228–32Google Scholar
  18. 18.
    Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drug events: implications for prevention. JAMA 1995; 274(1): 29–34PubMedCrossRefGoogle Scholar
  19. 19.
    Blum KV, Abel SR, Urbanski CJ, et al. Medication error prevention by pharmacists. Am J Hosp Pharm 1988 Sep; 45: 1902–3PubMedGoogle Scholar
  20. 20.
    Bobb A, Gleason K, Husch M, et al. The epidemiology of prescribing errors: the potential impact of computerized prescriber order entry. Arch Intern Med 2004 Apr; 164(7): 785–92PubMedCrossRefGoogle Scholar
  21. 21.
    Cimino MA, Kirschbaum MS, Brodsky L, et al. Assessing medication prescribing errors in pediatric intensive care units. Pediatr Crit Care Med 2004 Mar; 5(2): 124–32PubMedCrossRefGoogle Scholar
  22. 22.
    Edwards KL, Todd MW, Hogan TT. Evaluation of pre-scribing errors in a teaching hospital [abstract]. ASHP Midyear Clinical Meeting 1996 Dec; 31: 61EGoogle Scholar
  23. 23.
    Folli HL, Poole RL, Benitz WE, et al. Medication error prevention by clinical pharmacists in two children’s hospitals. Pediatrics 1987 May; 79(5): 718–22PubMedGoogle Scholar
  24. 24.
    Fox GD, Restino MS, Byerly WG, et al. Identification of prescribing error patterns in a teaching hospital [abstract]. ASHP Midyear Clinical Meeting 1997 Dec; 32: 139EGoogle Scholar
  25. 25.
    Granberry HE, Wright CC, Oldag KL, et al. Admission medication order reconciliation for pediatric patients [abstract]. ASHP Midyear Clinical Meeting 2005; 40: 95DGoogle Scholar
  26. 26.
    Grasso BC, Genest R, Jordan CW, et al. Use of chart and record reviews to detect medication errors in a state psychiatric hospital. Psychiatr Serv 2003 May; 54(5): 677–81PubMedCrossRefGoogle Scholar
  27. 27.
    Hendey GW, Barth BE, Soliz T. Overnight and postcall errors in medication orders. Acad Emerg Med 2005 Jul; 12(7): 629–34PubMedCrossRefGoogle Scholar
  28. 28.
    Johnson KB, Butta JK, Donohue PK, et al. Discharging patients with prescriptions instead of medications: sequelae in a teaching hospital. Pediatrics 1996 Apr; 97(4): 481–5PubMedGoogle Scholar
  29. 29.
    Kaushal R, Bates DW, Landrigan C, et al. Medication errors and adverse drug events in pediatric inpatients. JAMA 2001 Apr; 285(16): 2114–20PubMedCrossRefGoogle Scholar
  30. 30.
    King WJ, Paice N, Rangrej J, et al. The effect of computerized physician order entry on medication errors and adverse drug events in pediatric inpatients. Pediatrics 2003; 112(3): 506–9PubMedCrossRefGoogle Scholar
  31. 31.
    Leape LL, Cullen DJ, Clapp MD, et al. Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. JAMA 1999 Jul; 282(3): 267–70PubMedCrossRefGoogle Scholar
  32. 32.
    Lesar TS, Lomaestro BM, Pohl H. Medication-prescribing errors in a teaching hospital: a 9-year experience. Arch Intern Med 1997 Jul; 157(14): 1569–76PubMedCrossRefGoogle Scholar
  33. 33.
    Potts AL, Barr FE, Gregory DF, et al. Computerized physician order entry and medication errors in a pediatric critical care unit. Pediatrics 2004 Jan; 113(1): 59–63PubMedCrossRefGoogle Scholar
  34. 34.
    Schumock GT, Guenette AJ, Keys TV, et al. Prescribing errors for patients about to be discharged from a university teaching hospital [letter]. Am J Hosp Pharm 1994 Sep; 51: 15Google Scholar
  35. 35.
    StClair AT, Ofosu JR. Tracking potential prescribing errors in a pediatric teaching hospital [abstract]. ASHP Midyear Clinical Meeting 1995 Dec; 30: P202Google Scholar
  36. 36.
    Terceros Y, Chahine-Chakhtoura C, Malinowski JE, et al. Impact of a pharmacy resident on hospital length of stay and drug-related costs. Ann Pharmacother 2007; 41(5): 742–8PubMedCrossRefGoogle Scholar
  37. 37.
    Togashi CT, Akahoshi PC, Lamp CD, et al. Pharmacist intervention of medication prescribing errors in a university teaching hospital [abstract]. ASHP Midyear Clinical Meeting 1991 Dec; 26: P327EGoogle Scholar
  38. 38.
    Wang JK, Herzog NS, Kaushal R, et al. Prevention of pediatric medication errors by hospital pharmacists and the potential benefit of computerized physician order entry. Pediatrics 2007 Jan; 119(1): E77–85PubMedCrossRefGoogle Scholar
  39. 39.
    West DW, Levine S, Magram G, et al. Pediatric medication order error rates related to the mode of order transmission. Arch Pediatr Adolesc Med 1994 Dec; 148(12): 1322–6PubMedCrossRefGoogle Scholar
  40. 40.
    Scarsi KK, Fotis MA, Noskin GA. Pharmacist participation in medical rounds reduces medication errors. Am J Health Syst Pharm 2002 Nov; 59(21): 2089–92PubMedGoogle Scholar
  41. 41.
    Barber N, Franklin BD, Cornford T, et al. Safer, faster, better? Evaluating electronic prescribing: report to the Patient Safety Research Programme 2006 [online]. Available from URL: http://www.pcpoh.bham.ac.uk/publichealth/psrp/documents/PS019_Final_Report_Barber.pdf [Accessed 2008 Jul 2]
  42. 42.
    McFadzean E, Isles C, Moffat J, et al. Is there a role for a prescribing pharmacist in preventing prescribing errors in a medical admission unit? Pharm J 2003 Jun; 270: 896–9Google Scholar
  43. 43.
    Rees S, Thomas P, Shetty A, et al. Drug history errors in the acute medical assessment unit quantified by use of the NPSA classification. Pharm J 2007 Oct; 279: 469–71Google Scholar
  44. 44.
    Shulman R, Singer M, Goldstone J, et al. Medication errors: a prospective cohort study of hand-written and computerised physician order entry in the intensive care unit. Crit Care 2005 Oct; 9(5): R516–21PubMedCrossRefGoogle Scholar
  45. 45.
    Tully MP, Parker D, Buchan I, et al. Patient safety research programme. Medication errors 2: pilot study. Report prepared for the Department of Health, 2006 [online]. Available from URL: http://www.pcpoh.bham.ac.uk/publichealth/psrp/documents/PS020_Final_Report_Cantril.pdf [Accessed 2008 Jul 2]
  46. 46.
    Dale A, Copeland R, Barton R. Prescribing errors on medical wards and the impact of clinical pharmacists. Int J Pharm Pract 2003; 11(1): 19–24CrossRefGoogle Scholar
  47. 47.
    Dean B, Schachter M, Vincent C, et al. Prescribing errors in hospital inpatients: their incidence and clinical significance. Qual Saf Health Care 2002 Dec; 11(4): 340–4PubMedCrossRefGoogle Scholar
  48. 48.
    Dobrzanski S, Hammond I, Khan G, et al. The nature of hospital prescribing errors. Br J Clin Gov 2002; 7(3): 187–93CrossRefGoogle Scholar
  49. 49.
    Franklin BD, O’Grady K, Donyai P, et al. The impact of a closed-loop electronic prescribing and administration system on prescribing errors, administration errors and staff time: a before-and-after study. Qual Saf Health Care 2007; 16(4): 279–84PubMedCrossRefGoogle Scholar
  50. 50.
    Franklin BD, O’Grady K, Paschalides C, et al. Providing feedback to hospital doctors about prescribing errors: a pilot study. Pharm World Sci 2007 Jun; 29(3): 213–20PubMedCrossRefGoogle Scholar
  51. 51.
    Haw C, Stubbs J. Prescribing errors at a psychiatric hospital. Pharm Pract 2003; 13(2): 64–6Google Scholar
  52. 52.
    Mandal K, Fraser SG. The incidence of prescribing errors in an eye hospital. BMC Ophthalmology 2005 Mar 22; 5(1): 4PubMedCrossRefGoogle Scholar
  53. 53.
    Olsen S, Neale G, Schwab K, et al. Hospital staff should use more than one method to detect adverse events and potential adverse events: incident reporting, pharmacist surveillance and local real-time record review may all have a place. Qual Saf Health Care 2007 Feb; 16(1): 40–4PubMedCrossRefGoogle Scholar
  54. 54.
    Ridley SA, Booth SA, Thompson CM. Prescription errors in UK critical care units. Intensive Care Society’s Working Group on Adverse Incidents. Anaesthesia 2004 Dec; 59(12): 1193–200PubMedCrossRefGoogle Scholar
  55. 55.
    Sagripanti M, Dean B, Barber N. An evaluation of the process-related medication risks for elective surgery patients from pre-operative assessment to discharge. Int J Pharm Pract 2002; 10(3): 161–70CrossRefGoogle Scholar
  56. 56.
    Stubbs J, Haw C, Taylor D. Prescription errors in psy-chiatry-a multi-centre study. J Psychopharmacol 2006; 4: 553–61CrossRefGoogle Scholar
  57. 57.
    Webbe D, Dhillon S, Roberts CM. Improving junior doctor prescribing: the positive impact of a pharmacist intervention. Pharm J 2007 Feb; 278(7437): 136–8Google Scholar
  58. 58.
    Wilson DG, McArtney RG, Newcombe RG, et al. Medication errors in paediatric practice: insights from a continuous quality improvement approach. Eur J Pediatr 1998 Sep; 157(9): 769–74PubMedCrossRefGoogle Scholar
  59. 59.
    Forster AJ, Halil RB, Tierney MG. Pharmacist surveillance of adverse drug events. Am J Health Syst Pharm 2004; 61(14): 1466–72PubMedGoogle Scholar
  60. 60.
    Ho L, Brown GR, Millin B. Characterization of errors detected during central order review. C J Hosp Pharm 1992; 45(5): 193–7Google Scholar
  61. 61.
    Vira T, Colquhoun M, Etchells E. Reconcilable differences: correcting medication errors at hospital admission and discharge. Qual Saf Health Care 2006; 15(2): 122–6PubMedCrossRefGoogle Scholar
  62. 62.
    Fijn R, Van den Bemt PM, Chow M, et al. Hospital prescribing errors: epidemiological assessment of predictors. Br J Clin Pharmacol 2002 Mar; 53(3): 326–31PubMedCrossRefGoogle Scholar
  63. 63.
    Van den Bemt PMLA, Postma MJ, Van Roon EN, et al. Cost-benefit analysis of the detection of prescribing errors by hospital pharmacy staff. Drug Saf 2002; 25(2): 135–43PubMedCrossRefGoogle Scholar
  64. 64.
    Van Gijssel-Wiersma DG, Van den Bemt PM, Walenbergh-van Veen MC. Influence of computerised medication charts on medication errors in a hospital. Drug Saf 2005; 28(12): 1119–29PubMedCrossRefGoogle Scholar
  65. 65.
    Aneja S, Bajaj G, Mehandiratta SK. Errors in medication in a pediatric ward. Indian Pediatr 1992 Jun; 29(6): 727–30PubMedGoogle Scholar
  66. 66.
    Pote S, Tiwari P, D’Cruz S. Medication prescribing errors in a public teaching hospital in India: a prospective study. Pharm Pract 2007; 5(1): 17–20Google Scholar
  67. 67.
    Dawson KP, Penna AC, Drummond D, et al. Prescription errors in a children’s ward: audit and intervention. Aust J Hosp Pharm 1993; 23(5): 326–8Google Scholar
  68. 68.
    Parke J. Risk analysis of errors in prescribing, dispensing and administering medications within a district hospital. J Pharm Pract Res 2006; 36(1): 21–4Google Scholar
  69. 69.
    Lustig A. Medication error prevention by pharmacists: an Israeli solution. Pharm World Sci 2000 Feb; 22(1): 21–5PubMedCrossRefGoogle Scholar
  70. 70.
    Oliven A, Michalake I, Zalman D, et al. Prevention of prescription errors by computerized, on-line surveillance of drug order entry. Int J Med Inf 2005 Jun; 74(5): 377–86CrossRefGoogle Scholar
  71. 71.
    Baci VV, Beirevi-Laan M, Bozikov V, et al. Prescribing medication errors in hospitalised patients: a prospective study. Acta Pharmaceutica 2005 Jun; 55(2): 157–67Google Scholar
  72. 72.
    Colpaert K, Claus B, Somers A, et al. Impact of computerized physician order entry on medication prescription errors in the intensive care unit: a controlled cross-sectional trial. Crit Care 2006 Feb; 10(1): R21PubMedCrossRefGoogle Scholar
  73. 73.
    Lepaux DJ, Schmitt E, Dufay E. Fighting medication errors: results of a study and reflections on causes and ways for prevention. Int J Risk Saf Med 2002; 15(4/3): 203–11Google Scholar
  74. 74.
    Lisby M, Nielsen LP, Mainz J. Errors in the medication process: frequency, type, and potential clinical consequences. Int J Qual Health Care 2005; 17(1): 15–22PubMedCrossRefGoogle Scholar
  75. 75.
    Sangtawesin V, Kanjanapattanakul W, Srisan P, et al. Medication errors at Queen Sirikit National Institute of Child Health. J Med Assoc Thai 2003 Aug; 86 Suppl. 3: S570–5PubMedGoogle Scholar
  76. 76.
    Villegas AC, Lopez Herrara M, Lopez De Heredia I, et al. Medication errors in a neonatal intensive care unit (NICU) [abstract]. Patient Safety Research —Shaping the European Agenda Conference; 2007 Sep 24–26; PortoGoogle Scholar
  77. 77.
    Dean B, Barber N, Schachter M. What is a prescribing error? Qual Saf Health Care 2000 Dec; 9(4): 232–7CrossRefGoogle Scholar
  78. 78.
    NCC MERP Index for catorgorizing medication errors [online]. Available from URL: http://www.nccmerp.org/pdf/indexBW2001-06-12.pdf [Accessed 2008 Jul 5]
  79. 79.
    NPSA risk assessment tool for assessing the level of investigation required, and the external reporting requirements to the NPSA, following adverse incidents involving patients [online]. Available from URL: http://www.npsa.nhs.uk/site/media/documents/537_annex%20f%20npsa%20risk%20assessment%20tool.doc [Accessed 2008 Jul 2]
  80. 80.
    Nuckols TK, Bell DS, Liu H, et al. Rates and types of events reported to established incident reporting systems in two US hospitals. Qual Saf Health Care 2007 Jun; 16(3): 164–8PubMedCrossRefGoogle Scholar
  81. 81.
    Thomas EJ, Petersen LA. Measuring errors and adverse events in health care. J Gen Intern Med 2003 Jan; 18(1): 61–7PubMedCrossRefGoogle Scholar
  82. 82.
    Evans RS, Pestotnik SL, Classen DC, et al. A computer-assisted management program for antibiotics and other antiinfective agents. N Engl J Med 1998 Jan; 338(4): 232–8PubMedCrossRefGoogle Scholar
  83. 83.
    Ash JS, Sittig DF, Poon EG, et al. The extent and importance of unintended consequences related to computerized provider order entry. J Am Med Inform Assoc 2007 Jul; 14(4): 415–23PubMedCrossRefGoogle Scholar
  84. 84.
    Tobaiqy M, McLay J, Ross S. Foundation year 1 doctors and clinical pharmacology and therapeutics teaching: a retrospective view in light of experience. Br J Clin Pharmacol 2007 Sep; 64(3): 363–72PubMedCrossRefGoogle Scholar
  85. 85.
    Phansalkar S, Hoffman JM, Nebeker JR, et al. Pharmacists versus non-pharmacists in adverse drug event detection: a meta-analysis and systematic review. Am J Health Syst Pharm 2007 Apr; 64(8): 842–9PubMedCrossRefGoogle Scholar

Copyright information

© Adis Data Information BV 2009

Authors and Affiliations

  • Penny J. Lewis
    • 1
  • Tim Dornan
    • 2
  • David Taylor
    • 3
  • Mary P. Tully
    • 1
  • Val Wass
    • 2
  • Darren M. Ashcroft
    • 1
  1. 1.School of Pharmacy and Pharmaceutical SciencesUniversity of ManchesterManchesterUK
  2. 2.Manchester Medical School Education Research GroupManchesterUK
  3. 3.Liverpool Medical School Education Research GroupLiverpoolUK

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