How useful are voluntary medication error reports? The case of warfarin-related medication errors.

BACKGROUND: A study was conducted to explore the value and limitations of voluntary medical error reports and to learn about common errors in warfarin use. METHODS: Voluntary reports of 8,837 inpatient errors and 820 outpatient errors in warfarin use submitted by 445 hospitals and 192 outpatient facilities participating in MEDMARX, a voluntary medication error reporting system, from 2002 to 2004, were gathered. RESULTS: Overall, errors occurred most often during transcription/documentation (35%) and administration (30%) in hospitals, and during prescribing (31%) and dispensing (39%) in outpatient settings. Dosing errors were the most common type. In hospitals, more than 50% of reported errors were initiated by nurses, and 50% were intercepted by nurses, whereas in outpatient settings, about 50% of reported errors occurred in pharmacies and 50% were intercepted by pharmacists. About 17% of inpatient and 13% of outpatient warfarin errors resulted in changes in patient care, and 42% of inpatient and 62% of outpatient errors resulted in procedural changes. Cascade analysis and textual descriptions further located specific, correctible safety lapses. DISCUSSION: Voluntary medical error reporting systems can, to some extent, provide meaningful and actionable information to guide patient safety improvement, but their usefulness is limited because of a lack of details, incomplete reporting, underreporting, and various reporting biases.

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.

Harmful medication errors in children: a 5-year analysis of data from the USP's MEDMARX program.

Harmful pediatric medication errors are common in hospitals and health systems. Understanding what products are involved in these errors is important in the prevention of future errors. We used data from a voluntary medication error reporting system (MEDMARX) and identified 816 harmful outcomes involving 242 medications during a 5-year period. Eleven medications accounted for more than one third of reported errors (n = 261 or 34.5%). Wrong dosing and omission errors were common and were associated with therapeutic classes such as opioid analgesics (e.g., morphine and fentanyl), antimicrobial agents (e.g., vancomycin and gentamicin), and antidiabetic agents (e.g., insulin). Older commonly used agents still resulted in a substantial number of harmful pediatric medication errors and should be included in the focus of patient safety activities.

Potential benefits and problems with computerized prescriber order entry: analysis of a voluntary medication error-reporting database.

PURPOSE: The potential benefits and problems associated with computerized prescriber-order-entry (CPOE) systems were studied. METHODS: A national voluntary medication error-reporting database, Medmarx, was used to compare facilities that had CPOE with those that did not have CPOE. The characteristics of medication errors reportedly caused by CPOE were explored, and the text descriptions of these errors were qualitatively analyzed. RESULTS: Facilities with CPOE reported fewer inpatient medication errors and more outpatient medication errors than facilities without CPOE, but the statistical significance of these differences could not be determined. Facilities with CPOE less frequently reported medication errors that reached patients (p < 0.01) or harmed patients (p < 0.01). More than 7000 CPOE-related medication errors were reported over seven months in 2003, and about 0.1% of them resulted in harm or adverse events. The most common CPOE errors were dosing errors (i.e., wrong dose, wrong dosage form, or extra dose). Both quantitative and qualitative analyses indicate that CPOE could lead to medication errors not only because of faulty computer interface, mis-communication with other systems, and lack of adequate decision support but also because of common human errors such as knowledge deficit, distractions, inexperience, and typing errors. CONCLUSION: A national, voluntary medication error-reporting database cannot be used to determine the effectiveness of a CPOE system in reducing medication errors because of the variability in the number of reports from different institutions. However, it may provide valuable information on the specific types of errors related to CPOE systems.

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.

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.

Selected medication-error data from USP's MEDMARX program for 2002.

PURPOSE: Records from USP's MEDMARX database of medication errors for 2002 were studied. METHODS: Records of medication errors submitted to MEDMARX by participating health care institutions during 2002 were analyzed for error category index (whether a medication error actually occurred, whether it reached the patient, and, if so, the effect), node (the point in the medication-use process where the error occurred), type of error, cause, contributing factors, and drug products involved. RESULTS: The number of participating institutions was 482, and the number of medication error records released to MEDMARX was 192,477, an 82.2% increase from 2001. Errors that did not reach the patient were seen in 35% of the records, errors that reached the patient were seen in 49%, and errors that may have contributed to or resulted in harm were seen in 2%. The nodes, types of errors, causes of errors, contributing factors, and leading products by generic name are discussed. CONCLUSION: An analysis of over 192,000 records of medication errors submitted by nearly 500 health care facilities to USP's MEDMARX database in 2002 produced detailed information on the scope and nature of medication errors.

Medication errors: experience of the United States Pharmacopeia (USP) MEDMARX reporting system.

Medication errors are pervasive in America's 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 Prevention's 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.