Medication Errors in a Tertiary Hospital With Three Different Drug Delivery Systems

Abstract

ObjectiveTo estimate the proportion of medication errors in a tertiary hospital, global and for each delivery medication system, to describe the error types and the implied medications, and to analyse the factors associated to the same ones. MethodsErrors were identified from direct observation of 2242 opportunities for error (administered doses or prescribed doses not given) by 6 couples of observers. Delivery medication systems were stock in ward, unit-dose with electronic prescription, and unit dose with computerized transcription. Logistic regression was used to evaluate the association between errors and certain factors. ResultsThe medication error rate was 7.2% (95% CI, 6.1–8.3), and 4.4% (95% CI, 3.6–5.3) of them reached the patient. For delivery systems, the error rate was 9.5% (95 CI, 7.4–11.9) for stock in ward, 7.8% (95% CI, 5.9–10.0) for electronic prescription, and 4.7% (95% CI, 3.4–6.4) for computerized transcription. The highest error frequency was observed in the administration phase (58.4%) and the omitted dose was the most prevalent error (31.7%). The error rate was associated with the pharmacotherapeutic process, the schedule of administration, and the unit of hospitalization. ConclusionsIn 1 of each 14 opportunities for error, a medication error takes place. The different delivery medication systems have different error rates.