Patient Safety Study Documents Medication Errors in Hospitals

According to a new national report issued today by the United States Pharmacopeia (USP)'s Center for the Advancement of Patient Safety (CAPS), administering drugs using incorrect techniques continues to be a serious cause of injury to hospital patients, increasing costs to insurers. The study collected reported medication errors voluntarily provided by 368 health care facilities nationwide, including community, government, and teaching institutions. Of the 105,603 errors documented, the vast majority were corrected before causing harm to the patient. But 2.4 percent of the total errors were more serious, resulting in patient injury, prolonged hospitalization and even death.

From the United States Pharmacopeia:

National Patient Safety Study Documents Medication Errors in Hospitals
Administering Drugs Using Wrong Technique Harmful to Patients and Costly to Insurers

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Rockville, Maryland — According to a new national report issued today by the United States Pharmacopeia (USP)'s Center for the Advancement of Patient Safety (CAPS), administering drugs using incorrect techniques continues to be a serious cause of injury to hospital patients, increasing costs to insurers.

Summary of Information Submitted to MedmarxSM in the Year 2001: A Human Factors Approach to Medication Errors is an analysis of medication errors captured in 2001 by Medmarx, the anonymous, national reporting database operated by USP. This third annual report is the most comprehensive compilation of data available, reporting on 105,603 medication errors, which were voluntarily provided by 368 health care facilities nationwide, including community, government, and teaching institutions.

Of the 105,603 errors documented by Medmarx, the vast majority of errors were corrected before causing harm to the patient. However, 2,539, or 2.4 percent of the total errors, resulted in patient injury. Of this number, 353 errors required initial or prolonged hospitalization, 70 required intervention to sustain life, and 14 resulted in a patient's death.

Incorrect Administration Techniques, Pediatric & Emergency Room Errors
The Medmarx 2001 data report found that more cases of patient harm ensued when hospital staff applied incorrect administration techniques for medications or administered incorrect dosages of drugs. "What we're seeing are similarities among hospitals across the country," said Diane Cousins, R.Ph., vice president of CAPS at USP. "Our data indicates that the wrong administration technique, such as the improper dilution of IV products, was almost four times more likely to cause harm in hospital patients."

Patients involved in these harmful errors often required intensive care, which usually triggered longer hospital stays, extensive testing, additional monitoring, and more drug therapy — ultimately increasing the use of hospital resources and costs to health care systems.

The Medmarx 2001 data report indicates that health care facilities attribute medication errors to many causes, and often cite distractions (47 percent), workload increases (24 percent) and staffing issues (36 percent) as contributing factors.

Additionally, weight calculations are critical in determining appropriate medication dosages for children. Miscalculations in patient weight conversions from pounds to kilograms, which result in improper dosing errors, were common in pediatric departments. Failure to record drug allergies also was identified as a top pediatric mistake.

In the emergency department, the combination of interruptions and multiple concurrent tasks is prevalent in medication errors. More than 58 percent of emergency department errors can be attributed to an improper dose, an omission, or a prescribing error (i.e. wrong drug, wrong dose or incorrect directions). Heparin, a blood thinner used to treat and prevent blood clots, received the most reports of improper dosage. Diltiazem (for hypertension and angina) and pediatric diphtheria tetanus toxoid (vaccine for disease prevention) were also frequently cited for improper dosages.

Lawmakers Support Medication Error Reporting
Additionally, lawmakers have recognized the value of such a database. During the 2002 Congressional Year, Sen. Ted Kennedy (D-Mass.) and Rep. Nancy Johnson (R-Conn.) both sponsored legislation that encourages error reporting to voluntary systems such as Medmarx. "I commend U.S. Pharmacopeia for this useful report," said Sen. Kennedy. "USP's medication error reporting systems play an important role in improving the safety of patients. The new report highlights the need for effective action by Congress to strengthen national reporting systems and protect all patients."

Consumers can obtain a free brochure on how to safely use prescription and over-the-counter medications called Think It Through: A Guide to Managing the Benefits and Risks of Medicines. This brochure is available on the Internet at www.usp.org/thinkitthrough.

For more information on Medmarx, to receive a copy of the 2001 data report or to request Medmarx b-roll, send an e-mail to mediarelations@usp.org.