John P. Santell

Medication Errors: Experience of the United States Pharmacopeia (USP) MEDMARX Reporting System

Medication errors are pervasive in Americas health care system. MEDMARX is an Internet‐accessible, anonymous medication error reporting program designed for hospitals and health systems to systematically collect, analyze, and report medication errors. This study examined 154,816 medication error reports that were submitted to MEDMARX between January 1, 1999, and December 31, 2001. Data fields analyzed were error category (based on the National Coordinating Council for Medication Error Reporting and Preventions Error Category Index), type(s) of error, cause(s) of error, contributing factor(s), and product(s) involved. Approximately two‐thirds of the errors reported reached the patient, with relatively few causing harm. Death was reported in 19 occurrences. Errors of omission and improper dose/quantity were the most commonly reported. Performance deficit and procedure/protocol not followed were consistently identified as causes of error. Distractions and workload increase were often cited as contributing factors. There was a similar pattern of products reported in each of the years. Implications for quality assurance, clinical practice, and health policy are presented.

Reconciliation Failures Lead to Medication Errors

Poor communication of medical information at transition points of care--at admission, transfer, and discharge--often results in medication errors, but various strategies can reduce the likelihood of error.

Medication Errors: Experience of the United States Pharmacopeia (USP)

This article in this new department introduces USPs error-reporting programs and efforts to help health care practitioners reduce the occurrence and severity of medication errors.

Medication Errors Involving Wrong Administration Technique

Wrong administration technique has consistently been one of the most harmful types of medication error in health systems participating in MEDMARX. Administration technique errors typically are made by nurses administering medications on the patient care unit, although errors in administration technique also occur in other phases of medication use and involve other health care personnel and locations. The most commonly reported causes of error have been performance deficit, failure to follow procedures or protocols, and knowledge deficit. Educating and training health care personnel on proper administration techniques and use of infusion pumps and dispensing devices could reduce the risk of error. The drug products most often associated with administration technique errors and patient harm could be targeted in staff education and training programs.

Medication errors related to product names.

Confusion arising from product naming practices can result in unauthorized drug and improper dose/quantity errors. Efforts by FDA, drug manufacturers, pharmacists, other health care professionals, and patients can reduce the risk of these errors.