Skip to main content

Prevalence, Incidence and Nature of Prescribing Errors in Hospital Inpatients

A Systematic Review

Drug Safety volume 32, pages 379–389 (2009)Cite this 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.

This is a preview of subscription content, access via your institution.

Access options

Buy single article

Instant access to the full article PDF.

USD 49.95

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Fig. 1

References

  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): 370–6

    PubMed  Article  CAS  Google Scholar 

  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): 301–6

    PubMed  Article  CAS  Google Scholar 

  3. Phillips DP, Christenfeld N, Glynn LM. Increase in US medication-error deaths between 1983 and 1993. Lancet 1998 Feb; 351(9103): 643–4

    PubMed  Article  CAS  Google Scholar 

  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): 307–11

    PubMed  Article  CAS  Google Scholar 

  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. 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): 1908–16

    PubMed  Google Scholar 

  7. Lesar TS, Briceland L, Stein DS. Factors related to errors in medication prescribing. JAMA 1997 Jan; 277(4): 312–7

    PubMed  Article  CAS  Google Scholar 

  8. Morrill GB, Barreuther C. Screening discharge prescriptions. Am J Hosp Pharm 1988 Sep; 45(9): 1904–5

    PubMed  CAS  Google Scholar 

  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): R16

    Google Scholar 

  10. Gethins B. Wise up to medication errors. Pharm Pract 1996 Oct; 6: 323–8

    Google Scholar 

  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): 661–70

    PubMed  Article  Google Scholar 

  12. Ghaleb MA, Barber N, Franklin BD, et al. Systematic review of medication errors in pediatric patients. Ann Pharmacother 2006 Oct; 40(10): 1766–76

    PubMed  Article  Google Scholar 

  13. Maidment ID, Lelliott P, Paton C. Medication errors in mental healthcare: a systematic review. Qual Saf Health Care 2006 Dec; 15(6): 409–13

    PubMed  Article  Google Scholar 

  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): 891–900

    Article  Google Scholar 

  15. Allan EL, Barker KN. Fundamentals of medication error research. Am J Hosp Pharm 1990 Mar; 47(3): 555–71

    PubMed  CAS  Google Scholar 

  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): 1411–26

    PubMed  Article  Google Scholar 

  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; 228–32

  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): 29–34

    PubMed  Article  CAS  Google Scholar 

  19. Blum KV, Abel SR, Urbanski CJ, et al. Medication error prevention by pharmacists. Am J Hosp Pharm 1988 Sep; 45: 1902–3

    PubMed  CAS  Google Scholar 

  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): 785–92

    PubMed  Article  Google Scholar 

  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): 124–32

    PubMed  Article  Google Scholar 

  22. Edwards KL, Todd MW, Hogan TT. Evaluation of pre-scribing errors in a teaching hospital [abstract]. ASHP Midyear Clinical Meeting 1996 Dec; 31: 61E

    Google Scholar 

  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): 718–22

    PubMed  CAS  Google Scholar 

  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: 139E

    Google Scholar 

  25. Granberry HE, Wright CC, Oldag KL, et al. Admission medication order reconciliation for pediatric patients [abstract]. ASHP Midyear Clinical Meeting 2005; 40: 95D

    Google Scholar 

  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): 677–81

    PubMed  Article  Google Scholar 

  27. Hendey GW, Barth BE, Soliz T. Overnight and postcall errors in medication orders. Acad Emerg Med 2005 Jul; 12(7): 629–34

    PubMed  Article  Google Scholar 

  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): 481–5

    PubMed  CAS  Google Scholar 

  29. Kaushal R, Bates DW, Landrigan C, et al. Medication errors and adverse drug events in pediatric inpatients. JAMA 2001 Apr; 285(16): 2114–20

    PubMed  Article  CAS  Google Scholar 

  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): 506–9

    PubMed  Article  Google Scholar 

  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): 267–70

    PubMed  Article  CAS  Google Scholar 

  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): 1569–76

    PubMed  Article  CAS  Google Scholar 

  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): 59–63

    PubMed  Article  Google Scholar 

  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: 15

    Google Scholar 

  35. StClair AT, Ofosu JR. Tracking potential prescribing errors in a pediatric teaching hospital [abstract]. ASHP Midyear Clinical Meeting 1995 Dec; 30: P202

    Google Scholar 

  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): 742–8

    PubMed  Article  Google Scholar 

  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: P327E

    Google Scholar 

  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): E77–85

    PubMed  Article  Google Scholar 

  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): 1322–6

    PubMed  Article  CAS  Google Scholar 

  40. Scarsi KK, Fotis MA, Noskin GA. Pharmacist participation in medical rounds reduces medication errors. Am J Health Syst Pharm 2002 Nov; 59(21): 2089–92

    PubMed  Google Scholar 

  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. 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: 896–9

    Google Scholar 

  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: 469–71

    Google Scholar 

  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): R516–21

    PubMed  Article  Google Scholar 

  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. Dale A, Copeland R, Barton R. Prescribing errors on medical wards and the impact of clinical pharmacists. Int J Pharm Pract 2003; 11(1): 19–24

    Article  Google Scholar 

  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): 340–4

    PubMed  Article  CAS  Google Scholar 

  48. Dobrzanski S, Hammond I, Khan G, et al. The nature of hospital prescribing errors. Br J Clin Gov 2002; 7(3): 187–93

    Article  Google Scholar 

  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): 279–84

    PubMed  Article  Google Scholar 

  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): 213–20

    PubMed  Article  Google Scholar 

  51. Haw C, Stubbs J. Prescribing errors at a psychiatric hospital. Pharm Pract 2003; 13(2): 64–6

    Google Scholar 

  52. Mandal K, Fraser SG. The incidence of prescribing errors in an eye hospital. BMC Ophthalmology 2005 Mar 22; 5(1): 4

    PubMed  Article  CAS  Google Scholar 

  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): 40–4

    PubMed  Article  Google Scholar 

  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): 1193–200

    PubMed  Article  CAS  Google Scholar 

  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): 161–70

    Article  Google Scholar 

  56. Stubbs J, Haw C, Taylor D. Prescription errors in psy-chiatry-a multi-centre study. J Psychopharmacol 2006; 4: 553–61

    Article  Google Scholar 

  57. Webbe D, Dhillon S, Roberts CM. Improving junior doctor prescribing: the positive impact of a pharmacist intervention. Pharm J 2007 Feb; 278(7437): 136–8

    Google Scholar 

  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): 769–74

    PubMed  Article  CAS  Google Scholar 

  59. Forster AJ, Halil RB, Tierney MG. Pharmacist surveillance of adverse drug events. Am J Health Syst Pharm 2004; 61(14): 1466–72

    PubMed  Google Scholar 

  60. Ho L, Brown GR, Millin B. Characterization of errors detected during central order review. C J Hosp Pharm 1992; 45(5): 193–7

    CAS  Google Scholar 

  61. Vira T, Colquhoun M, Etchells E. Reconcilable differences: correcting medication errors at hospital admission and discharge. Qual Saf Health Care 2006; 15(2): 122–6

    PubMed  Article  CAS  Google Scholar 

  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): 326–31

    PubMed  Article  CAS  Google Scholar 

  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): 135–43

    PubMed  Article  Google Scholar 

  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): 1119–29

    PubMed  Article  Google Scholar 

  65. Aneja S, Bajaj G, Mehandiratta SK. Errors in medication in a pediatric ward. Indian Pediatr 1992 Jun; 29(6): 727–30

    PubMed  CAS  Google Scholar 

  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): 17–20

    Google Scholar 

  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): 326–8

    Google Scholar 

  68. Parke J. Risk analysis of errors in prescribing, dispensing and administering medications within a district hospital. J Pharm Pract Res 2006; 36(1): 21–4

    Google Scholar 

  69. Lustig A. Medication error prevention by pharmacists: an Israeli solution. Pharm World Sci 2000 Feb; 22(1): 21–5

    PubMed  Article  CAS  Google Scholar 

  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): 377–86

    Article  Google Scholar 

  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): 157–67

    Google Scholar 

  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): R21

    PubMed  Article  Google Scholar 

  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): 203–11

    Google Scholar 

  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): 15–22

    PubMed  Article  Google Scholar 

  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: S570–5

    PubMed  Google Scholar 

  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; Porto

  77. Dean B, Barber N, Schachter M. What is a prescribing error? Qual Saf Health Care 2000 Dec; 9(4): 232–7

    Article  CAS  Google Scholar 

  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. 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. 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): 164–8

    PubMed  Article  Google Scholar 

  81. Thomas EJ, Petersen LA. Measuring errors and adverse events in health care. J Gen Intern Med 2003 Jan; 18(1): 61–7

    PubMed  Article  Google Scholar 

  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): 232–8

    PubMed  Article  CAS  Google Scholar 

  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): 415–23

    PubMed  Article  Google Scholar 

  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): 363–72

    PubMed  Article  Google Scholar 

  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): 842–9

    PubMed  Article  Google Scholar 

Download references

Acknowledgements

The authors would like to thank Kathryn Bell for her assistance with data extraction.

This systematic review was commissioned by the UK General Medical Council to contribute to the evidence base informing policy developments. The authors have no conflicts of interest that are directly relevant to the content of this review.

The protocol was designed by all authors. The searches were designed by Penny J. Lewis and Darren M. Ashcroft and conducted by Penny J. Lewis. All authors were involved in extracting data from the publications. Penny J. Lewis and Darren M. Ashcroft analysed the results and Penny J. Lewis prepared the first draft of the review. All authors commented on subsequent drafts.

Author information

Authors and Affiliations

  1. School of Pharmacy and Pharmaceutical Sciences, University of Manchester, Stop-ford Building, Oxford Rd, Manchester, M13 9PT, UK

    Penny J. Lewis, Mary P. Tully & Darren M. Ashcroft

  2. Manchester Medical School Education Research Group, Manchester, UK

    Tim Dornan & Val Wass

  3. Liverpool Medical School Education Research Group, Liverpool, UK

    David Taylor

Authors
  1. Penny J. Lewis
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Tim Dornan
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. David Taylor
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Mary P. Tully
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Val Wass
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Darren M. Ashcroft
    View author publications

    You can also search for this author in PubMed Google Scholar

Electronic supplementary material

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Lewis, P.J., Dornan, T., Taylor, D. et al. Prevalence, Incidence and Nature of Prescribing Errors in Hospital Inpatients. Drug-Safety 32, 379–389 (2009). https://doi.org/10.2165/00002018-200932050-00002

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.2165/00002018-200932050-00002

Keywords

  • Medication Error
  • Incident Report
  • Computerize Physician Order Entry
  • Medication Order
  • Electronic Prescription