In a prospective cohort study published in the Sept. 9 issue of the Archives of Internal Medicine, the most common medication errors made in 36 hospitals and skilled nursing facilities were wrong time, omission, wrong dose, or unauthorized drug.
Overall, there were errors made in 19% of doses, and 7% were potentially harmful. This study is “a useful reminder of how we’re doing,” Kasey K. Thompson, PharmD, director of the Center on Patient Safety at the American Society of Health-System Pharmacists in Bethesda, Maryland, tells WebMD. “It’s looking at expected failures from poorly designed systems of care in hospitals.This study tells us there are things we need to do to help our practitioners do better rather than just lay blame and punish.”
Of a stratified random sample of 36 hospitals accredited by the Joint Commission on Accreditation of Healthcare Organizations, nonaccredited hospitals, and skilled nursing facilities in Georgia and Colorado, 26 declined to participate in the study, and were replaced with other facilities chosen at random.
The investigators analyzed medication doses given or omitted by nurses on high medication-volume nursing units during at least one medication-pass during a one-to-four-day period. Trained observers witnessed and recorded medication errors, which were verified by a research pharmacist. In the 36 institutions, 605 (19%) of 3216 doses were in error. The most commonly made errors were wrong time (43%), omission (30%), wrong dose (17%), and unauthorized drug (4%). Potentially harmful errors, judged to be potential adverse drug events, were made in 7% of doses, or more than 40 errors per day in a typical 300-patient facility.
אנו מציעים לך כלי עזר זמין אשר שימוש מושכל בו עשוי למנוע טעויות מינון וטעויות אחרות – מאגר התרופות שלנו עומד לרשותך בכל עת
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