Rodney W. Hicks

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.

National Study on the Frequency, Types, Causes, and Consequences of Voluntarily Reported Emergency Department Medication Errors

BACKGROUND Medication errors contribute to significant morbidity, mortality, and costs to the health system. Little is known about the characteristics of Emergency Department (ED) medication errors. STUDY OBJECTIVE To examine the frequency, types, causes, and consequences of voluntarily reported ED medication errors in the United States. METHODS A cross-sectional study of all ED errors reported to the MEDMARX system between 2000 and 2004. MEDMARX is an anonymous, confidential, de-identified, Internet-accessible medication error-reporting program designed to allow hospitals to report, track, and share error data in a standardized format. RESULTS There were 13,932 medication errors from 496 EDs analyzed. The error rate was 78 reports per 100,000 visits. Physicians were responsible for 24% of errors, nurses for 54%. Errors most commonly occurred in the administration phase (36%). The most common type of error was improper dose/quantity (18%). Leading causes were not following procedure/protocol (17%), and poor communication (11%), whereas contributing factors were distractions (7.5%), emergency situations (4.1%), and workload increase (3.4%). Computerized provider order entry caused 2.5% of errors. Harm resulted in 3% of errors. Actions taken as a result of the error included informing the staff member who committed the error (26%), enhancing communication (26%), and providing additional training (12%). Patients or family members were notified about medication errors 2.7% of the time. CONCLUSION ED medication errors may be a result of the acute, crowded, and fast-paced nature of care. Further research is needed to identify interventions to reduce these risks and evaluate the effectiveness of these interventions.

Medication errors involving patient-controlled analgesia

PURPOSE The magnitude, frequency, and nature of nonharmful and harmful medication errors associated with patient-controlled analgesia (PCA) were studied. METHODS A retrospective analysis of Medmarx, a national voluntary medication error-reporting database, was conducted for the period from July 1, 2000, to June 30, 2005, to identify all PCA-related medication errors. Quantitative analysis of the records included the severity of each error, type of error, phase in the medication-use process, principal cause, contributing factors, actions taken, and drug and staff involved. A qualitative analysis was also performed. RESULTS Over the five-year review period, 919,241 medication errors records from 801 facilities were submitted to Medmarx. Of these, 9,571 (1%) were associated with PCA. There were 624 records of PCA associated with harm, corresponding to 6.5% of the patients. Errors were reported across all phases of the medication-use process, but the majority occurred during drug administration. Over one third (38%) involved an improper dosage or quantity, while 17.4% involved an omission and 17.3% an unauthorized or wrong drug. Overwhelmingly, human factors were the main cause of PCA errors. Equipment issues (19.5%) and similar drug names and product packaging (11.6%) were also implicated. Distractions (37.8%) and inexperienced staff (26.3%) were the leading contributing factors. Harmful errors required more institutional resources than nonharmful medication errors to manage. Prescribers often issued incomplete, duplicative, or contradictory orders or failed to adjust dosages for comorbid conditions. Dispensing errors were often associated with misfills from the automated dispensing cabinet, compounding of a wrong strength, or lack of drug product availability. Administration errors involved the wrong drug, amount, or concentration, often because the PCA device was misprogrammed. CONCLUSION Events during all phases of the medication-use process contributed to PCA-related medication errors, many of which harmed patients.

An overview of intravenous-related medication administration errors as reported to MEDMARX, a national medication error-reporting program.

Medication errors can be harmful, especially if they involve the intravenous (IV) route of administration. A mixed-methodology study using a 5-year review of 73,769 IV-related medication errors from a national medication error reporting program indicates that between 3% and 5% of these errors were harmful. The leading type of error was omission, and the leading cause of error involved clinician performance deficit. Using content analysis, three themes—product shortage, calculation errors, and tubing interconnectivity—emerge and appear to predispose patients to harm. Nurses often participate in IV therapy, and these findings have implications for practice and patient safety. Voluntary medication error-reporting programs afford an opportunity to improve patient care and to further understanding about the nature of IV-related medication errors.

Characteristics of pediatric chemotherapy medication errors in a national error reporting database

Little is known regarding chemotherapy medication errors in pediatrics despite studies suggesting high rates of overall pediatric medication errors. In this study, the authors examined patterns in pediatric chemotherapy errors.

Enteral Feeding Misconnections: A Consortium Position Statement

A consortium of organization identified solutions to the problem of enteral feeding misconnections in three areas: (1) education, awareness, and human factors; (2) purchasing strategies; and (3) design changes.

Patient-Controlled Analgesia-Related Medication Errors in the Postoperative Period: Causes and Prevention

Patient-controlled analgesia (PCA) is a common and effective means of managing postoperative pain. Unfortunately, the complex processes and equipment associated with the setup, programming and administration of intravenous or epidural PCA have allowed it to become a significant source of preventable medication errors. These errors can be classified into two major categories: human (operator) errors and equipment errors (malfunctions). Such errors are potentially harmful to patients, time-consuming for hospital staff and costly for healthcare providers. The objective of this article is to describe PCA medication errors and examine systems and modalities that may help reduce the incidence of system-related errors. Data from the US FDA’s Manufacturer and User Facility Device Experience (MAUDE) database indicate that 6.5% of intravenous PCA-related events were due to operator error. Most (81%) of these errors were due to pump misprogramming, of which almost half were associated with patient harm; 76.4% of adverse events were attributed to device malfunction (e.g. due to frayed wires or a crack in the drug cartridge), although only 0.5% of these were associated with harm to patients. In a report based on data from MEDMARX®, a voluntary database that captures reports on medication errors, 7.9% of the PCA-related errors captured over a 5-year period were described as causing harm to patients. Technological advances, such as improved PCA pump designs based on ergonomic and cognitive engineering principles, the use of barcode technology and other ‘smart pump’ safety features, and new postoperative pain management modalities, may play a significant role in reducing the future incidence and severity of PCA medication errors.

Errors prevented by and associated with bar-code medication administration systems.

As expected, bar-code medication administration systems can prevent medication errors. However, health care organizations must be aware of identified failure points in bar coding that may contribute to errors.

The Rate and Costs Attributable to Intravenous Patient-Controlled Analgesia Errors:

Purpose To estimate the rates and costs of intravenous patient-controlled analgesia (IV PCA) errors from the hospital or integrated health system perspective. Methods This study used a cost-accounting methodology to estimate the costs attributable to IV PCA errors in the United States. Data for the study were obtained from the MEDMARX and Manufacturer and User Facility Device Experience (MAUDE) datasets, published literature, and expert opinions. MEDMARX is a voluntary, anonymous, medication-error-reporting database owned and operated by the United States Pharmacopeia. MAUDE is a mandatory, device-error-reporting database maintained by the US Food and Drug Administration. Levels of care rendered as a result of the IV PCA errors were estimated by applying clinical assumptions (validated by an expert advisory panel) to each of the 7 error consequences considered in this analysis. Variable and opportunity costs (2006 values) were considered, including medication, laboratory, lost revenue, and labor. The corresponding costs were applied to the error consequences to derive the estimated mean cost for each error cause. The numbers of errors documented in each dataset and the published literature were used to extrapolate the rate of IV PCA errors annually. Results The average cost per error event was

Medication Errors in the OR—A Secondary Analysis of Medmarx

733 in the MEDMARX dataset and