Wrong Route Of Administration Research Articles

A Simple and Versatile Method for Ex Vivo Monitoring of Goat Vaginal Mucosa Transduction by Viral Vector Vaccines.

Goat may represent a valid large animal model for human pathogens and new vaccines testing. Appropriate vaccine administration is a critical component of a successful immunization program. The wrong route of administration may reduce the efficacy of the vaccine, whereas the proper administration strategy can enhance it. Viral vectors have been employed successfully for goat and sheep immunization; however, no data concerning the vaginal route are available. A viral vector's ability to transduce the site of inoculation is of primary interest. In this study, a fast and reliable ex vivo assay for testing the transduction capability of an Ad5-based vector when intravaginally administered was developed. An Ad5 vector delivering an expression cassette with a bicistronic reporter gene, Ad5-CMV-turboGFP-IRES-Luc2, was constructed. We demonstrated Ad5-CMV-turboGFP-IRES-Luc2's ability to transduce caprine vaginal mucosa by ex vivo bioluminescent imaging (BLI) employing a simple CCD camera apparatus for chemiluminescence western immunoblotting. These data, though simple, provide valuable insights into developing a vaginal immunization strategy using a viral vector-based vaccine to protect against pathogens causing genital diseases.

An Overview on Prescription Error

An overview of prescription errors among patients is studied. A prescription error is defined as a therapeutic process failure that results in or may result in patient damage. Errors with prescriptions states that at least 1.5 million people are harmed annually by one of the most prevalent medical blunders. While there are many benefits of using medicines, as well as there are also risks, which might occur due to prescription errors. One of the most frequent ways that patients suffer is from improper prescription management, which is often the result of prescribing errors. The methods to lower prescription errors are examined in this evidence scan. Finding the cause of prescription errors and raising public awareness are its two main goals to reduce errors. Make errors or inconsistencies in the selection and administration of medications, such as incorrect dosages, wrong route of administration, and unnoticed drug interaction. Prescription errors are more likely to occur in older adults. Errors in prescription drugs raise health care expenses and reduces patient trust in the medical system. Managers and health experts are constantly searching for methods to raise the standard and guarantee the security of healthcare. This document discusses medication errors, which are instances of drug mis adventuring that should be avoided by implementing efficient system controls. These controls should involve pharmacists, doctors, nurses, risk management staff, attorneys, administrators, patients, and other members of the organizational setting in addition to regulatory bodies and the pharmaceutical industry

The Influence of Monitoring, Evaluation, And Teamwork Effectiveness on Principle 7 Correct Implementation of Drug Administration in Non-Covid-19 Inpatient in Hospitals

Errors in drug administration were ranked first (24.8%) of the top 10 incidents reported in hospitals. The types of errors that caused death in patients included 40.9%, wrong dose, 16% wrong drug, and 9.5% wrong route of administration. The purpose of this study was to analyze the influence of monitoring, evaluation, and teamwork effectiveness on the implementation of the 7 correct principles of drug administration. This research is a quantitative analysis with a cross-sectional approach. The research was conducted at Hospital Pematang Siantar. The study population was 103 people and all of them were used as samples (total sampling). Data were analyzed using univariate, bivariate with chi-square test, and multivariate with multiple logistic regression at 95% confidence level (a=0.05). The results showed that the implementation of the 7 correct principles of drug administration at the non-Covid-19 Inpatient Installation at Hospital in Pematang Siantar was influenced by monitoring variables (p=0.000), evaluation (p=0.036), teamwork effectiveness (p=0.042). The monitoring variable has a greater influence on the implementation of the 7 right principles of drug administration with a value of OR = 10.643 meaning that nurses who say monitoring is good have the opportunity to implement the 7 right principles of drug administration properly by 10.6 times higher than nurses who say monitoring is not good. The conclusion of the study is that monitoring, evaluation and teamwork effectiveness affect the implementation of the 7 principles of correct drug administration. It is recommended that the hospital can carry out continuous monitoring and evaluation regarding the procedures that have been established as a benchmark for achieving SOPs that are applied in implementing the 7 correct principles of drug administration. Nurses need to increase the effectiveness of teamwork (teamwork) so as to minimize the adverse impact on the patients served.

Impact of selected clinical pharmacy services on medication safety and prescription cost of patients attending a selected primary healthcare setting: a translational experience from a resource-limited country.

The impact of clinical pharmacy (CP) services on primary healthcare (PH) is less well studied in resource-limited countries. We aimed to evaluate the effect of selected CP services on medication safety and prescription cost at a PH setting in Sri Lanka. Patients attending a PH medical clinic with medications prescribed at the same visit were selected using systematic random sampling. A medication history was obtained and medications were reconciled and reviewed using four standard references. Drug-related problems (DRPs) were identified and categorised, and severities were assessed using the National Coordinating Council Medication Error Reporting and Prevention Index. Acceptance of DRPs by prescribers was assessed. Prescription cost reduction due to CP interventions was assessed using Wilcoxon signed-rank test at 5% significance. Among 150 patients approached, 51 were recruited. Nearly half (58.8%) reported financial difficulties in purchasing medications. DRPs identified were 86. Of them, 13.9% (12 of 86) DRPs were identified when taking a medication history (administration errors (7 of 12); self-prescribing errors (5 of 12)), 2.3% (2 of 86) during reconciliation, and 83.7% (72 of 86) during medication reviewing (wrong indication (18 of 72), wrong strength (14 of 72), wrong frequency (19 of 72), wrong route of administration (2 of 72), duplication (3 of 72), other (16 of 72)). Most DRPs (55.8%) reached the patient, but did not cause harm. Prescribers accepted 65.8% (56 of 86) DRPs identified by researchers. The individual prescription cost reduced significantly due to CP interventions (p<0.001). Implementing CP services could potentially improve medication safety at a PH level even in resource-limited settings. Prescription cost could be significantly reduced for patients with financial difficulties in consultation with prescribers.

Impact of selected clinical pharmacy services on medication safety and prescription cost of patients attending a selected primary healthcare setting: a translational experience from a resource-limited country

Purpose of the studyThe impact of clinical pharmacy (CP) services on primary healthcare (PH) is less well studied in resource-limited countries. We aimed to evaluate the effect of selected CP...

How do your patients use their medicines at home and why is it important to know?

Medication safety is a hot topic around the world but tends to focus on what professionals believe about prescribing, supply and safe administration of medicines.1 Historically, less attention has been...

A case of accidental vincristine overdose and effective use of therapeutic plasma exchange in its management

AbstractVincristine is a common drug used in hematological malignancy with a maximum per dose limited to 2 mg mainly to limit neurotoxicity. Vincristine overdose and wrong route of administration, though has been reported in world literature, but its appropriate management is still undefined. We report a case of Hodgkin lymphoma being treated with adriamycin, bleomycin, vinblastine and dacarbazine protocol, where vincristine was accidently administrated instead of vinblastine due to its “look-alike, sound-alike” nature. The patient developed severe toxicity due to the same, which was effectively managed by therapeutic plasma exchange.

Medication Errors Associated with Look-alike/Sound-alike Drugs: A Brief Review

The existence of confusing drug names is one of the most common causes of medication errors. There are many types of medication errors: wrong drug, wrong dose, wrong route of administration, wrong patient etc. Misreading medication names that look similar is a common mistake. These look-alike medication names may also sound alike and can lead to errors associated with verbal prescriptions. Similar sounding drugs may produce confusion and may lead to unintended interchange of drugs causing harm to patients or even patient death. The main aim of the study was to evaluate medication errors related to look alikesound alike drug names and to find out the strategies to prevent these medication errors.J Enam Med Col 2015; 5(2): 110-117

THE ROLE OF THE PAEDIATRIC CLINICAL PHARMACIST IN REDUCING MEDICATION ERRORS: A SYSTEMATIC LITERATURE REVIEW

Aim Clinical pharmacists in some countries are a recognised primary source for providing evidence based (where possible) information and advice, to ensure delivery of the correct, safest and most effective medication to patients.1 We wished to determine from the literature: the effect of paediatric clinical pharmacists9 activities on reducing medication error rates; the nature of pharmacists9 interventions to minimise or prevent medication errors in children; other pharmacists9 contributions to patient care. Methods Systematic search of five databases: EMBASE, International Pharmaceutical Abstracts, Ovid MEDLINE(R), Allied and Complementary Medicine and Cumulative Index to Nursing and Allied Health Literature to end of July 2013, using 74 keywords. Inclusion criteria: original research studies identifying the effect of pharmacists9 activities on reducing/detecting medication errors in neonatal or paediatric patients, or in the general population, where neonatal or paediatric data was separately identified. Results Twenty-five relevant studies were identified in 13 different countries (mostly the US followed by the UK). Studies used three methods of data collection to detect medication errors: chart review, review of incident reports and direct observation of nurses and parents administering medications. Pharmacists identified prescribing, administration and medication errors in general (where the type of error was not specified). Nine studies provided only the number of errors intercepted with no denominator. The remaining 16 studies identified the error rate using seven different denominators. These methodological variations made studies very difficult to compare. Pharmacists intercepted 29 types of medication errors, most commonly: wrong dose (21 studies); wrong drug (11); wrong route of administration (8); incomplete prescriptions (8) and omission of medications (8). Antibiotics were the most common group of medications where interventions were made. The acceptance rate of pharmacists9 recommendations by doctors was identified by nine studies and ranged between 24% (in US) and 98% (in Canada). Pharmacists made 15 different types of contributions. The most common were: provision of information in response to other healthcare professionals9 queries (7 studies); cost savings (e.g. €532 per patient saved in a German paediatric neurology ward as a result of preventing wastage of medications) (5); medication reconciliation (3); education of patients/parents in drug administration to facilitate adherence (3). Education was another successful initiative highlighted in six studies e.g. education of doctors decreased the prescribing dosing error rate from 61.8 to 1.3% of all orders in an Indian specialist children9s hospital.2 It decreased the nurse administration error rate from 40.4% to 7.9% of all administrations and parents from 96.6% to 5.6% of all administrations in Germany.3 Conclusion Paediatric clinical pharmacists use a wide range of initiatives to reduce and prevent medication errors mainly in the US and the UK. Little information is available from other parts of the world where such activities are also likely to be valuable.

Description of medication errors detected at a drug information centre in Southern Brazil.

To identify and describe actual or potential medication errors related to drug information inquiries made by staff members of a teaching hospital to a Drug Information Centre from January 2012 to December 2013. Data were collected from the records of inquiries made by health care professionals to the Drug Information Centre throughout this period. During the study period, the Drug Information Centre received 3,500 inquiries. Of these, 114 inquiries had medication errors. Most errors were related to prescribing, preparation, and administration and were classified according to severity as category B (57%) (potential errors) and categories C (26.3%) and D (15.8%) (actual errors that did not result in harm to the patient). Error causes included overdose (13.2%), wrong route of administration (11.4%), inadequate drug storage (11.4%), and wrong dosage form (8.8%). The drugs most frequently involved in errors were vitamin K (4.4%), vancomycin (3.5%), and meropenem (3.5%). In this study, it was not possible to measure the reduction in error rate involving medication use because of the lack of previous data on this process in the institution. However, our findings indicate that the Drug Information Centre may be used as a strategy to seek improvements in processes involving medication use.

Effect of Barcode-assisted Medication Administration on Emergency Department Medication Errors

Barcode-assisted medication administration (BCMA) is technology with demonstrated benefit in reducing medication administration errors in hospitalized patients; however, it is not routinely used in emergency departments (EDs). EDs may benefit from BCMA, because ED medication administration is complex and error-prone. A naïve observational study was conducted at an academic medical center implementing BCMA in the ED. The rate of medication administration errors was measured before and after implementing an integrated electronic medical record (EMR) with BCMA capacity. Errors were classified as wrong drug, wrong dose, wrong route of administration, or a medication administration with no physician order. The error type, severity of error, and medications associated with errors were also quantified. A total of 1,978 medication administrations were observed (996 pre-BCMA and 982 post-BCMA). The baseline medication administration error rate was 6.3%, with wrong dose errors representing 66.7% of observed errors. BCMA was associated with a reduction in the medication administration error rate to 1.2%, a relative rate reduction of 80.7% (p < 0.0001). Wrong dose errors decreased by 90.4% (p < 0.0001), and medication administrations with no physician order decreased by 72.4% (p = 0.057). Most errors discovered were of minor severity. Antihistamine medications were associated with the highest error rate. Implementing BCMA in the ED was associated with significant reductions in the medication administration error rate and specifically wrong dose errors. The results of this study suggest a benefit of BCMA on reducing medication administration errors in the ED.

Do High‐Risk Medicines Alerts Influence Practice?

ABSTRACTBackgroundMedicine‐related adverse events are prevalent, costly and mostly preventable. The High Risk Medicines Working Party (Victoria) developed and distributed three high‐risk medicines alerts – wrong route of administration of oral medicines, subcutaneous insulin and unfractionated heparin – and accompanying audit tools in 2008 and 2009.AimsTo determine the impact of the three high‐risk medicines alerts on Victorian health services; to assess the clinical relevance and utility of the audit tools; to identify barriers to implementing recommendations; and to obtain feedback and suggestions for future alert topics.MethodA cross‐sectional survey was undertaken from 6 to 31 July 2009 using an online questionnaire. The questionnaire was distributed to 90 metropolitan, regional and rural public health services in Victoria and approximately 200 members of the Quality Use of Medicines Network (Victoria).ResultsMost of the 90 respondents were pharmacists (53%) and nurses (31%). 53 (59%) respondents reported making changes as a result of receiving the high‐risk medicines alerts – 21 (40%) concerned the wrong route of administration, 12 (23%) subcutaneous insulin and 7 (13%) unfractionated heparin. Barriers to implementation included time constraints, inadequate staff and resources, excessive paperwork and competing priorities. A minority of respondents indicated some alerts were not relevant to small rural services. Suggestions for improving the audit tools included making them less labour intensive, enabling electronic responses and ensuring their distribution is coordinated with other medicine‐related tools.ConclusionHigh‐risk medicines alerts and the accompanying audit tools facilitated change but there were some barriers to their implementation, such as time and resource constraints. Not all alerts and audit tools were relevant to all health services.

Iatrogenic intravenous medication errors reported to the GIZ-Nord Poisons Center Göttingen

Background We analyzed the iatrogenic intravenous medication errors (IIME) reported to the GIZ-Nord Poisons Center Göttingen. Methods IIME over a ten year period were analyzed retrospectively and categorized into error types, age groups, drugs involved, and severity of IIME at registration and after known outcome. Results 265 IIME were registered from 1997 to 2006. They rose from 12 in 1997 to 45 in 2006 corresponding to an increase from 0.058 to 0.148% of all calls of the respective year. Children were affected in (21.1%) and adults in 78.9% of all cases. The drug classes (ATC classification) involved most frequently were antipsychotics (7.9%) and antithrombotic agents (6.0%). The main types of IIME were dosing error (37.7%) and wrong route of administration (28.7%). The severity of IIME at registration was none (33.6%), minor (32.5%), moderate (13.6%), severe (13.6%), fatal (1.5%), and unratable (5.2%). In the 46 cases followed to a known outcome, 15 were asymptomatic and 27 were symptomatic with minor (11 cases), moderate (5 cases) and severe features (11 cases). Four cases of IIME were already fatal at registration and one severe case died in the further course. Dosing error of theophylline was often observed in severe outcomes. Conclusion IIME increased from 1997 to 2006. Intravenous use of antipsychotics and theophylline should be restricted to a minimum.

Quarter Watch: 2008 Quarter 1 : QUARTER WATCH PROJECT TEAM

EXECUTIVE SUMMARY A record number of deaths and serious injuries associated with drug therapy were reported to the US Food and Drug Administration (FDA) in the first quarter of 2008. Serious injuries associated with drug therapy reached a total of 20,745 new cases; there were a total of 4,824 reported deaths, a 2.6-fold increase from the previous quarter. In addition, varenicline (Chantix, Champix), an aid to smoking cessation, accounted for more reported serious injuries than any other prescription drug for a second quarter, with a total of 1,001 new cases and including 50 additional deaths. Varenicline was the subject of a previ ous Quarter Watch Special Report and a separate FDA Public Health Alert about psychiatric adverse events. Ranked second in reported serious injuries was heparin, a drug that helps prevent injury from blood clots. Heparin was the subject of a major product recall after a potentially lethal contaminant was identified and traced to suppliers in China. In the first quarter of 2008, the FDA received reports of 779 cases of serious injury in which heparin was the principal suspect drug. These findings come from a program being developed by the Institute for Safe Medication Practices (ISMP) for improvement of patient safety through increasing understanding of how and why drugrelated injuries and medication errors occur. The results are from analyses of new adverse drug event reports submitted to the FDA. The agency releases computer excerpts of these reports for research use after personal-identifying information has been removed. However, the results of this monitoring program should be interpreted with caution because of the known limitations of these data and the nature of the overall system through which adverse events are monitored in the United States. Because reporting is voluntary, only a small fraction of adverse drug events that occur are ever reported to the FDA or to drug manufacturers who then investigate and forward reports to the agency. Although the sum totals of reported adverse event reports usually provide an accurate overall adverse event profile for a drug, the individual reports themselves do not prove that the drug caused the event described. Trends in Reported Cases Serious injuries and deaths associated with drug therapy were reported for a record total of 20,745 persons in the first quarter of 2008. The total was 38% higher than the average for the previous 4 quarters and the highest for any quarter. Reported deaths totaled 4,824 cases, a 2.6-fold increase over the previous quarter and the highest number of deaths in a calendar quarter since 2004. Fatal cases also accounted for a larger share of all serious cases, 23% of those in the first quarter of 2008 compared with an historical average of 16%. Identifiable medication errors accounted for 7.1% (1,464) of all cases of serious injury. The largest numbers of cases were divided evenly between errors of administration (wrong drug, wrong dose, or wrong route of administration) and overdoses (both accidental and intentional). Most drugs in medical use produced only a small number of reports of serious injury or death. One-half the 773 identifiable drugs tracked in the most recent quarter had 6 or fewer serious adverse events reported. Only 50 drugs accounted for 100 or more reported serious injuries. Hospital Pharmacy Volume 44, Number 1, pp 47–56 2009 Wolters Kluwer Health, Inc.

Medication Prescribing Errors Involving the Route of Administration

Context Administration of medications by the wrong route or as a wrong dose for the ordered route presents significant risk for adverse drug events. Objective To quantify and identify the characteristics of prescribing errors involving the route of drug administration. Design Evaluation of medication orders with errors involving the route of administration detected by pharmacists in a 631-bed tertiary care teaching hospital over a 42-month period. Main Outcome Measures Type, frequency, characteristics, potential for adverse effects, contributors, and enabling factors of medication prescribing errors involving the route of administration. Results A total of 862 prescribing errors were detected. Sixty-one different types of route-related prescribing errors, involving 135 different medications, were detected. The most common type of these errors involved prescribing the wrong route of administration (39.2%) and prescribing the same or similar medications to be given concurrently by two routes (21.1 %). The most common class of medications involved were cardiovascular agents (23.5%). The most common medication characteristic identified as contributing to route-related prescribing errors was the common and routine use of a drug by multiple routes (75.9%). Conclusions Prescribing errors involving the route of administration are common, occur in a wide variety of ways, and involve a wide variety of medications. A number of commonly recommended medication safety practices should reduce risk to patients from route-related medication prescribing errors.

Follow-up Study of Medication Errors Reported to the Vaccine Adverse Event Reporting System (VAERS)

A study was done to determine if the apparent medication errors found in the Vaccine Adverse Event Reporting System (VAERS) database are true errors, and if true errors are found, to determine what corrective action was taken. Furthermore, if a true error did not occur, we wanted to determine at what point the misinformation was entered into the system. The VAERS database was searched for reports received between July 1, 2001 and June 30, 2002 which had either been classified as "error" or the word "error" appeared in the text of the report. The database was also searched for reports which indicated that the measles-mumps-rubella (MMR), diphtheria-tetanus-pertussis (DTP), diphtheria-tetanus-acellular pertussis (DTaP) or diphtheria-tetanus-pertussis-haemophilus (DTPH) vaccinations had been administered at an age outside of the usual recommendation. A total of 119 reports of possible errors were found. Follow-up was successful in 102 (86%) cases. Additional information obtained showed that 26 cases were actual medication errors. Seventy-six cases were not actual medication errors; 9 cases were physician decisions, 37 cases were data entry errors and 30 cases were reporter errors. The nature of the actual errors was similar to those reported previously; wrong inoculum, improper interval, wrong route of administration, and overdose. Many errors could have been prevented by more attention to detail. Remedial action usually consisted of retraining. The new requirement that all medications be barcoded, purchasing products from different manufacturers and segregation of vials may help prevent vial confusion.

Bar Codes Coming To Medications Near You

Back to table of contents Previous article Next article Government NewsFull AccessBar Codes Coming To Medications Near YouChristine LehmannChristine LehmannSearch for more papers by this authorPublished Online:4 Apr 2003https://doi.org/10.1176/pn.38.7.0017aMedication errors are among the most common preventable mistakes in health care, according to a 1999 Institute of Medicine report. Experts have estimated that more than one million serious errors related to medication occur annually in hospitals alone.In an effort to reduce medication errors, the Food and Drug Administration (FDA) proposed two new rules last month as part of the agency’s strategic initiative to curb adverse events related to the products it regulates, according to an HHS press release.Tommy Thompson, secretary of Health and Human Services, announced the proposed rules last month. “These proposals are key steps in reducing medication problems through state-of-the-art technology,” said Thompson in the press release.The first rule would require bar codes on all prescription drugs, over-the-counter drugs packaged for hospital use, and vaccines.Thompson said that bar codes are already widely used in hospitals and other health care settings. The code would at minimum contain the National Drug Code (NDC) number, which identifies the drug, its strength, and dosage form.The FDA seeks comment on whether to add information such as lot number and expiration date.“The bar code, when used with a bar code scanner and computerized patient information systems, can prevent many medication errors, including giving the wrong drug to a patient, giving the drug to a patient who is allergic to it, giving the wrong dose or at the wrong time, or using the wrong route of administration, for example, by injection rather than by mouth,” said Thompson in the release.Thompson also announced a second FDA proposed rule designed to revamp the safety reporting requirements for medications. The rule would require companies that produce medications to submit to the FDA, within 15 calendar days, all reports they receive of actual and “near-miss” medication errors in the United Sates, according to the press release.One example of a “near-miss” is when a pharmacist selects the wrong medication because of a similar sounding name but catches the error prior to dispensing the medication.” The company would be required to report the potential error to the FDA if the pharmacist reported to the company what happened, according to the release.The proposal is also intended to promote uniform reporting standards among regulatory agencies in the United States and abroad.In addition, the proposal would require the submission of all suspected serious reactions for blood and blood products on the market.The proposal clarifies the kind of data needed in various safety reports to “lessen industry’s reporting burdens especially for certain suspected adverse reactions that are not serious. Companies can focus on producing high-quality reports for serious suspected adverse reactions, which potentially have a much greater public health impact,” said Thompson in the release.Fact sheets on both proposed rules and other related materials are posted on the FDA Web site at www.fda.gov/oc/initiatives/barcode-sadr. The public can submit comments on the proposed barcode rule until June 14 and on the safety reporting requirements until July 14 (90 and 120 days respectively from the March 14 publication in the Federal Register). Comments can be submitted online by accessing www.accessdata.fda.gov/scripts/oc/dockets/comments/commentdocket.cfm and clicking on “02N-0204—Bar Code Label Requirements for Human Drug Products” and “00N-1484—Safety Reporting Requirements for Human Drug and Biological Products.” Written comments on both proposed rules should be submitted by the same deadlines to the Dockets Management Branch (HFA-305), Food and Drug Administration, 5630 Fishers Lane, Room 1061, Rockville, Md. 20852. ▪ ISSUES NewArchived

Retrospective analysis of mortalities associated with medication errors.

The types, causes, contributing factors, and patient demographics of fatal medication errors were reviewed. Case reports of medication errors from hospitals, ambulatory care settings, and patients' homes that were entered in FDA's Adverse Event Reporting System during 1993-98 were the source of information on fatal medication errors. Each report was classified using predefined criteria and a taxonomy developed by the National Coordinating Council for Medication Error Reporting and Prevention. The types, causes, contributing factors, and patient demographics were identified, and the causality of each case was assessed to prevent future fatalities. The data indicated 5,366 medication error reports. Fifty-nine reports were excluded and classified as duplicate reports or intentional overdoses. Of the remaining medication error reports, 68.2% resulted in serious patient outcomes and 9.8% were fatal. Of the 469 fatal medication error reports, 48.6% occurred in patients over 60 years. The most common types of errors resulting in patient death involved administering an improper dose (40.9%), administering the wrong drug (16%), and using the wrong route of administration (9.5%). The most common causes of errors were performance and knowledge deficits (44%) and communication errors (15.8%). Fatal medication errors accounted for approximately 10% of medication errors reported to FDA and were most frequently the result of improper dosing of the intended drug and administration of an incorrect drug. A review of case reports of medication errors from 1993 to 1998 yielded information on the most frequent causes of and contributing factors involved in fatal medication errors.

Let's talk about error.

In the time it will take you to read this editorial, eight patients will be injured, and one will die, because of preventable medical errors. Medication error—wrong drug, wrong dose, wrong route of administration, wrong patient, or wrong time—is the most common single preventable cause of patient injury. When all sources of error are added up, the likelihood that a mishap will injure a patient in the hospital is at least 3%, and probably much higher.1,2,3,4 This is a serious public health problem. When one considers that a typical airline handles customers' baggage at a far lower error rate than we handle the administration of drugs to patients, it is also an embarrassment.

Low Dose Oestrogen Prophylaxis for Recurrent Urinary Tract Infections in Elderly Women

Objective To assess the efficacy of oral oestriol in the prevention of recurrent Urinary tract infections in elderly women. Design Double-blind, randomised, parallel group, placebo controlled trial Setting Urogynaecology Unit at King's College Hospital with some women recruited from the geriatric units of St. Pancras Hospital and Dulwich Hospital, London (UK). Participants Seventy-two postmenopausal women older than 60 years of age (mean 73.2 years) suffering from recurrent urinary tract infections. Intervention Oral oestriol (3 mg per day) or placebo for six months. Main outcome measures Urinary tract infection rates. Results The study was difficult to conduct because of its design and the age of the participants. Oral oestriol (3 mg per day) was not shown to be superior to placebo in the prevention of recurrent urinary tract infections, but both oestriol and placebo improved urinary symptoms during the trial. Conclusion The power of the study might have been too low to detect a significant difference between the groups, or oral oestriol(3 mg per day) may have been either the wrong dose or the wrong route of administration for this indication.