3
Medication Errors: Incidence and Cost

CHAPTER SUMMARY

Medication error rates are important for gauging the scope of the problem, setting priorities for prevention strategies, and measuring the impact of those strategies. This chapter summarizes the evidence base on rates of medication errors; preventable adverse drug events; and failure to prescribe medications for which the evidence supports the ability to reduce morbidity and mortality in hospital, nursing home, and ambulatory settings. An understanding of the costs of medication errors is important as well to inform decisions about the implementation of strategies designed to reduce the risk of medication errors. This chapter also summarizes the evidence base on these costs.

As noted in Chapter 1, the committee’s charge encompassed developing estimates of the incidence, severity, and costs of medication errors and evaluating alternative approaches to reducing such errors in different settings. To this end, the committee commissioned papers summarizing the salient peer-reviewed literature in the areas of hospital care, nursing home care, ambulatory care, pediatric care, psychiatric care, and use of over-the-counter (OTC) and complementary and alternative medications.1 The au-

1

The authors of the papers are as follows: for hospital care, Harvey J. Murff, MD, MPH, Vanderbilt University; for nursing home care, Ginette A. Pepper, PhD, RN, FAAN, University of Utah College of Nursing; for ambulatory care, Grace M. Kuo, PharmD, MPH, Baylor



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Preventing Medication Errors 3 Medication Errors: Incidence and Cost CHAPTER SUMMARY Medication error rates are important for gauging the scope of the problem, setting priorities for prevention strategies, and measuring the impact of those strategies. This chapter summarizes the evidence base on rates of medication errors; preventable adverse drug events; and failure to prescribe medications for which the evidence supports the ability to reduce morbidity and mortality in hospital, nursing home, and ambulatory settings. An understanding of the costs of medication errors is important as well to inform decisions about the implementation of strategies designed to reduce the risk of medication errors. This chapter also summarizes the evidence base on these costs. As noted in Chapter 1, the committee’s charge encompassed developing estimates of the incidence, severity, and costs of medication errors and evaluating alternative approaches to reducing such errors in different settings. To this end, the committee commissioned papers summarizing the salient peer-reviewed literature in the areas of hospital care, nursing home care, ambulatory care, pediatric care, psychiatric care, and use of over-the-counter (OTC) and complementary and alternative medications.1 The au- 1 The authors of the papers are as follows: for hospital care, Harvey J. Murff, MD, MPH, Vanderbilt University; for nursing home care, Ginette A. Pepper, PhD, RN, FAAN, University of Utah College of Nursing; for ambulatory care, Grace M. Kuo, PharmD, MPH, Baylor

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Preventing Medication Errors thors were asked to review this literature from the last 10 years2 (and earlier major studies if still relevant). Where possible, the five steps in the medication-use process were to be analyzed separately. Special attention was to be given to errors that arise during transfers between care settings, for example, from hospital to ambulatory care. In addition, the authors were asked to identify the approaches to reducing medication errors recommended by major health care organizations and to evaluate each approach in terms of the evidence/process used by these organizations to justify it. In addition, a paper was commissioned to review the non-peer-reviewed literature for approaches to reducing medication errors.3 The authors of the commissioned papers were encouraged to use a modified search strategy as described by Smeaton and colleagues (2002). They were also encouraged to search the following databases: MEDLINE, CINAHL (Cumulative Index to Nursing and Allied Health Literature), PsycINFO, IPA (International Pharmaceutical Abstracts), Science Citation Index, and Dissertation Abstracts. The authors tailored these suggestions to their own requirements. In summary, the study focused on English-language articles published in the period 1995–2005, augmented by earlier important studies and studies published after the literature reviews had been completed. The majority of studies reviewed were conducted in the United States. Where relevant, when there were no or few U.S. studies for a particular setting or study category, foreign studies are cited in the report, with the country of origin noted. Drawing on these commissioned papers, this chapter summarizes the committee’s findings on the incidence and costs of medication errors (more detail on incidence is given Appendix C). Chapter 5 summarizes the committee’s findings on prevention strategies as part of the recommended action agendas for each care setting (more detail on these strategies is given in Appendix D). INCIDENCE The extent of the research on the incidence of medication errors and adverse drug events (ADEs) varies greatly across care settings (see Appendix C); Box 3-1 summarizes the difficulties encountered by the committee College of Medicine; for pediatric care, Marlene R. Miller, MD, MSc, Karen A. Robinson, MSc, Lisa H. Lubornski, PhD, Michael L. Rinke, BA, and Peter J. Pronovost, MD, PhD, The Johns Hopkins University; for psychiatric care, Benjamin C. Grasso, MD, The Institute for Self-Directed Care; and for OTC and complementary and alternative medications, Albert I. Wertheimer, MBA, PhD and Thomas M. Santella, BS, Temple University. 2 The pediatric care paper examined peer-reviewed journals over the last 5 years. 3 Authored by Eta Berner, EdD, University of Alabama at Birmingham, and Richard Maisiak, PhD, MSPH, consultant.

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Preventing Medication Errors BOX 3-1 Difficulties in Synthesizing the Evidence on Incident Rates Since the publication of To Err Is Human: Building a Safer Health System (IOM, 2000), there has been a rapid growth in contributions to the field of patient safety. As with any emerging discipline, synthesizing the results of this research is challenging because of the heterogeneity of study definitions and error identification methodologies. Significant confusion exists about the most fundamental issue in quantifying medication errors. One broad definition of medication errors is any inappropriate use of a drug, regardless of whether that use resulted in harm (Nebeker et al., 2004). Other definitions include only medication errors that have the potential to produce harm, or “clinically significant medication errors” (Lesar et al., 1997). Thus a medication error that could never be executed, such as a prescription to give orally a medication that comes only in parenteral form, would be excluded. As discussed previously, medication use also involves various stages, including selecting and procuring the drug by the pharmacy, prescribing and selecting the drug for the patient, preparing and dispensing the drug, administering the drug, and monitoring the patient for effect, and many studies have focused on errors occurring during only one of these stages. Contributing to the heterogeneity of the patient safety literature are the varying methodologies used to identify errors. The incidence rates found in the literature depend dramatically on the particular detection method used. Although many such methods exist, those most commonly employed include direct observation, chart review, computerized monitoring, and voluntary reporting (Murff et al., 2003) (see Chapter 5 for more detail). Many studies have established that voluntary reporting results in marked underestimation of rates of medication errors and ADEs (Allan and Barker, 1990; Cullen et al., 1995; Jha et al., 1998; Flynn et al., 2002). Voluntary reporting rates are generally low because of such factors as time pressures, fear of punishment, and lack of a perceived benefit (Cullen et al., 1995). Improvements in internal reporting have been achieved in nonpunitive reporting environments (Rozich and Resar, 2001), but these rates still vastly underestimate the true incidence. A large study comparing direct observation, chart review, and incident reporting found that direct observation identified the greatest number of errors (Flynn et al., 2002). Earlier it had been established that automated surveillance could detect ADEs at a much higher rate than voluntary reporting. A comparison of automated surveillance, chart review, and voluntary reporting found that of the 617 ADEs detected, chart review identified 65 percent, automated surveillance 45 percent, and voluntary reporting 4 percent (Jha et al., 1998). In this study, only 12 percent of all ADEs detected were identified by both chart review and computerized surveillance (Jha et al., 1998). Several studies have noted that different methods of detection appear more suited to identifying different types of medication-related problems (O’Neil et al., 1993; Jha et al., 1998), suggesting that the method selected should depend on the area of interest (again, see Chapter 5 for more detail). In conclusion, the incidence rates found in the patient safety literature depend dramatically on the particular detection method used. A further confounding factor is that medication error rates are quoted in varying ways—errors per order/dose/opportunity, errors per 1,000 patient-days, and errors per 1,000 patient admissions. Rates of preventable ADEs are cited in a similar manner—preventable ADEs per 1,000 patient-days and per 1,000 patient admissions.

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Preventing Medication Errors in synthesizing this heterogeneous evidence base. Hospital care is the setting with the most extensive research. Studies have estimated the rate of ADEs incurred in hospitals and error rates at each stage of the medication-use process. There is also an extensive literature on errors of omission in prescribing—failure to prescribe medications in appropriate situations. Other care settings are much less well researched. For nursing home care, there are estimates of the rates of ADEs incurred while in a nursing home, plus a few studies on error rates at various stages of the medication-use process.4 Little attention has been paid to errors of omission in the nursing home population. For ambulatory care, a modest amount of research has been carried out, spread thinly over a large number of topics— ADE and error rates at various stages of the medication-use process, and omissions of effective therapies in specific populations. Similarly for pediatric care, a modest amount of research has been carried out, again thinly spread over a wide range of topics. For the remaining care settings considered in this report, little or no research has been conducted on ADE and error rates. Of the limited number of studies relating to self-care, most addressed adherence issues. No study was found on medication error rates in the school setting. Just two studies were found on medication error rates in psychiatric care. Finally, there has been hardly any research on medication errors relating to OTC medications, and no study was found on error rates associated with complementary and alternative medications. The discussion in this section is based on a large number of studies reviewed by the committee. It first addresses the incidence of medication errors in general, and then the incidence of three specific categories of medication errors—preventable ADEs, underutilization of medications, and overutilization of medications. Incidence of Medication Errors Hospitals As noted, hospital care is the most researched setting for medication error incidence rates, although no study was identified that addressed medi- 4 There have been many studies of inappropriate prescribing for the elderly in nursing homes, ambulatory care, and home health care, based on such criteria as the Beers criteria (Beers et al., 1991) and subsequent updates/extensions (Beers, 1997). The committee did not include these studies in its synthesis since the causal link between inappropriate prescribing and poor health outcomes has not been documented.

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Preventing Medication Errors cation errors in the selection and procurement of drugs by the hospital pharmacy. Medication errors occur in all stages of the medication-use process, most frequently at the prescribing and administration stages. Several U.S. studies using differing definitions of error and methods of error identification found that rates of prescribing errors for adults in hospitals varied considerably (see Table 3-1). Prescribing errors occurred at rates of 12.3– 1,400.00 per 1,000 patient admissions (Bates et al., 1995a; Lesar et al., 1997; Lesar, 2002; LaPointe and Jollis, 2003; Winterstein et al., 2004). Such errors occurred at rates of 0.6–53.0 per 1,000 orders (Lesar et al., 1990; Bates et al., 1995a; Lesar et al., 1997; Lesar, 2002). And in studies that evaluated prescribing errors per opportunity for error, rates of 1.5–9.9 per 100 opportunities were found (Dean et al., 2002; van den Bemt et al., 2002; Bobb et al., 2004; Lisby et al., 2005). Errors rates depend on the thoroughness of the error detection methods that are used (Gandhi et al., 2000). Most of the above studies used less comprehensive error detection methods, such as spontaneous reports by pharmacists after review of written orders (Lesar et al., 1997; Lesar, 2002), prompted reporting (Winterstein et al., 2004), and reporting by a clinical pharmacist participating in patient care (LaPointe and Jollis, 2003). The study that found by far the highest rate (Bates et al., 1995a) used much more comprehensive detection methods—chart review, including review of written medication orders by a dedicated trained reviewer, in addition to prompted reporting from nurses and pharmacists. This study found a rate of 1,400 prescribing errors per 1,000 patient admissions or 0.3 prescribing errors per patient per day. Of the errors identified, 7.5 percent were adjudged serious—preventable or potential ADEs. By comparison, a study (Kaushal et al., 2001) using similar error detection methods in pediatric units identified 405 prescribing errors per 1,000 patient admissions or 0.1 TABLE 3-1 Error Rates in Hospitals Prescribing errors Per 1,000 admissions 12.3–1,400 (5 studies)   Per 1,000 orders 0.61–53 (4 studies)   Per 100 opportunities for error 1.5–9.9 (4 studies) Administration errors Per 100 opportunities/doses 2.4–11.1 (5 studies)

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Preventing Medication Errors prescribing error per patient per day. In this study, 19.5 percent of the errors were adjudged serious—preventable or potential ADEs. Turning to medication administration errors, according to several international studies, administration errors (excluding wrong-time errors) are frequent, with error rates per dose ranging from 2.4 to 11.1 percent (Dean et al., 1995; Taxis et al., 1999; Barker et al., 2002; Tissot et al., 2003; Lisby et al., 2005). The U.S. study in this group found an administration error rate of 11 percent, excluding wrong-time errors (Barker et al., 2002). This study employed an observation-based method for detecting medication administration errors that has been used by the Centers for Medicare and Medicaid Services (CMS) for almost 20 years as a quality indicator for nursing homes. It was carried out in Colorado and Georgia in 36 different facilities (12 accredited hospitals, 12 nonaccredited hospitals, and 12 skilled nursing facilities). There was no significant difference in error rates (regardless of whether wrong-time errors were included) by type of facility. For the 36 facilities, the administration error rate (excluding wrong-time errors) ranged from 0 to 26 percent, with 8.3 percent as the median value. The 36 institutions studied were selected at random primarily from the Atlanta, Georgia, metropolitan statistical area and the Denver-Boulder-Greeley, Colorado, consolidated statistical area. Each facility had to agree to participate in the study. Twenty-six selected facilities declined to take part in the study. Most did not give reasons for not wishing to participate; of those that did, many expressed concerns about poor scores and wanting to improve their performance first (Barker et al., 2002). Thus the authors concluded that the error rates reported likely represent a lower bound. A study in five intensive care units (ICUs) in U.S. tertiary teaching facilities (Calabrese et al., 2001) found an administration error rate of 3.3 percent—lower than that reported in the above study. The ICU study identified administration errors for a group of high-alert medications using a similar observational technique. The authors of this study commented that the rates they obtained were lower than those found in a comparable French ICU study (Tissot et al., 1999), and suggested that this difference might be due to varying methods of observation and pharmacist participation in patient care in the U.S. study. The committee believes these results—while the best available for large ICUs in the United States—are not generalizable to non-ICU hospital care and that the study by Barker and colleagues (2002) represents the best estimate of administration error rates in U.S. hospitals for non-ICU care. Much higher rates of administration errors were observed in two studies that focused on intravenous medications—34 per 100 in a joint U.K./ German study (Wirtz et al., 2003) and 49 per 100 in a U.K. study (Taxis and Barber, 2003). On the basis of the Barker et al. (2002) study and assuming a patient in

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Preventing Medication Errors TABLE 3-2 Error Rates in Nursing Homes Administration errors Per 100 opportunities/doses 6 (Cooper et al., 1994) 12.2 (Barker et al., 1982) 14.7 (Barker et al., 2002) 20 (Baldwin, 1992) the hospital receives 10 doses of medication per day,5 a typical patient would be subject to one administration medication error per day. These data, taken together with the results of the above studies, which identified 0.1 prescribing error per patient per day (Kaushal et al., 2001) and 0.3 prescribing error per patient per day (Bates et al., 1995a), as well as plus the fact that medication errors occur in other stages of the medication-use process (e.g., errors in the prescribing and administration stages accounted for 77 percent of medication errors [Leape et al., 1995]), suggest to the committee that about one medication error occurs per patient per day in hospital care. Nursing Homes There is little information on rates of dispensing errors in nursing homes, since this function generally is outsourced. According to the available data (see Table 3-2), medication administration errors appear to occur in nursing homes at a rate of 6–20 per 100 doses (Barker et al., 1982, 2002; Baldwin, 1992; Cooper et al., 1994). The two main studies in this area, published 20 years apart, both used the same error detection method (direct observation) and reported similar error rates—12 errors per 100 doses (Barker et al., 1982), and 15 errors per 100 doses (Barker et al., 2002) (in both cases excluding doses administered at the wrong time). Excluding wrong-time errors, omission of an ordered medication is generally the most common type of drug administration error in nursing homes. Given that administration error rates are higher in nursing homes than in hospitals, it 5 Rates of doses dispensed in hospital are rarely quoted in the literature. At MountainView Hospital, Las Vegas, Nevada, dose rates increased steadily at about 10 percent per year over the period 2002–2006 (Wood and Nam, 2005). During this period, the average numbers of doses dispensed per patient per day were 13.6 (January 2002), 13.3 (July 2002), 15.8 (January 2003), 15.1 (July 2003), 16.8 (January 2004), 16.3 (July 2004), 19.5 (January 2005), 18.0 (July 2005), and 22.1 (January 2006). The committee also carried out a small survey of eight community and teaching hospitals in Pennsylvania, Michigan, Ohio, and Minnesota. Based on 2005 or 2006 data, for the three community hospitals, the results were 24.4, 20.6, and 12.2 doses per patient per day; and for the teaching hospitals, the results were 25.8, 29.7, 32.8, 22.3, and 20.9 doses per patient per day. These data suggest that the assumption of 10 doses per patient per day is a conservative one.

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Preventing Medication Errors is likely that per day, nursing home patients are more likely to experience a medication error than are hospital patients. Monitoring errors are probably the most common type of error in the nursing home setting, but are much more difficult to identify, and no study in this area was found. Because a typical medication pass in long-term care exceeds 2 hours, it is impossible for the nurse to deliver all medications within 1 hour of the scheduled time; thus wrong-time errors are predictably high in this setting. Finally, transitions from the nursing home to other settings are a time of high risk for adverse effects due to prescribing or transcription errors. Ambulatory Care For the purposes of this study, the committee examined medication error rates in six different settings within the ambulatory care domain: (1) the interface between care settings, for example, from hospital care to outpatient clinic; (2) the ambulatory clinic; (3) the community pharmacy; (4) the home care setting; (5) self-care; and (6) the school setting. In general, there is little or no understanding of incidence rates in all these areas. Error rates in ambulatory clinics have been thinly researched (see Table 3-3). One study found that 21 percent of prescriptions in these settings TABLE 3-3 Error Rates in Ambulatory Clinics Prescription writing errors Percentage of prescriptions containing at least one prescription writing error 21 (Shaughnessy and Nickel, 1989) Errors in an ambulatory hemodialysis unit Percentage of patients subject to prescribing errors 97.7 (Manley et al., 2003b)   Medication-related problems per patient per month 0.45 (Manley et al., 2003a) Errors in an ambulatory chemotherapy unit Percentage of doses containing an error 3 (Gandhi et al., 2005) Errors in dispensing samples Percentage of labels with usual dosage not present 12 (Dill and Generali, 2000)   Percentage of labels that referred user to enclosed prescribing information that was absent 17 (Dill and Generali, 2000) Documentation errors Current medications per patient missing from patient record 0.37 (Wagner and Hogan, 1996) 0.89 (Bedell et al., 2000)   Percentage of prescription renewals missing from patient record 15 (Ernst et al., 2001)

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Preventing Medication Errors TABLE 3-4 Errors by Community and Mail Order Pharmacies Community pharmacy: telephoned prescription errors Percentage of telephoned prescriptions containing an error 12.4 (Camp et al., 2003) Community pharmacy: dispensing errors Percentage of prescriptions erroneously dispensed 1.7 (Flynn et al., 2003) 3.4 (Buchanan et al., 1991) 12.5 (Kistner et al., 1994) 24 (Allan et al., 1995) Mail order pharmacy: dispensing errors Percentage of prescriptions erroneously dispensed 0.075 (Teagarden et al., 2005) contained at least one prescription writing error (Shaughnessy and Nickel, 1989). Two studies found high rates of medication errors in ambulatory hemodialysis units (Manley et al., 2003a,b). Extrapolating the findings of the study with the lower rate (Manley et al., 2003a) to the 246,000 U.S. hemodialysis patients, nearly 111,000 medication-related problems occur to these patients each month. In an ambulatory chemotherapy clinic, a medication error rate of 3.0 percent was found (Gandhi et al., 2005). Another study (Dill and Generali, 2000) found a lack of adequate documentation provided with drug samples available for administration to patients in an ambulatory clinic. Finally, three studies (Wagner and Hogan, 1996; Bedell et al., 2000; Ernst et al., 2001) found high rates of medication documentation errors. Regarding community pharmacies (see Table 3-4), one study (Camp et al., 2003) found that 12.4 percent of telephoned prescriptions contained an error in the information provided by the person calling in the prescription. Four studies examining dispensing errors and using the same error detection method found a wide range of prescription dispensing error rates—1.7 to 24 percent. One study conducted in a hospital-based outpatient pharmacy found the rate of dispensing errors to be 12.5 percent (Kistner et al., 1994). Another small-scale study found a 24 percent dispensing error rate (Allan et al., 1995). In a study at a high-volume outpatient pharmacy, the error rate was found to be 3.4 percent (Buchanan et al., 1991). These three studies published in the period 1991–1995, reported much higher error rates than a more recent study reflecting the likely improvements in dispensing systems and technology over time. This more recent, large-scale study of both new prescriptions and prescription refills found an error rate of 1.7 percent (Flynn et al., 2003). This dispensing error rate translates to approximately 4 errors per 250 prescriptions per pharmacy per day, or an

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Preventing Medication Errors estimated 51.5 million errors during the filling of 3 billion prescriptions each year. One study of medication errors at Medco Health Solutions, Inc., a large mail order pharmacy, carried out by Medco employees, found a dispensing error rate of 0.075 percent—16 dispensing errors among 21,252 prescriptions (Teagarden et al., 2005). Self-care studies have focused mainly on adherence rates, which are generally low. An early study found adherence rates for prescribed medications of 50 percent (Sackett and Snow, 1979). A more recent meta-analysis of 328 studies reporting on adherence to medication regimens found an adherence rate of 79.4 percent (DiMatteo, 2004). Adherence rates appear to vary according to the number of doses taken per day (Cramer et al., 1989). Pediatric Care It has become clear that the prescription, dispensing, and administration of medications account for a substantial portion of the preventable medical errors that occur with children (Kaushal et al., 2001, 2004). Children are uniquely vulnerable to medication errors: all pediatric medication doses need to be based on body-size parameters (e.g., weight, body mass index) and the state of organ development; children are much less able than adults to double-check their own medications; and the wide range of appropriate doses for any given medication based on the child’s size gives the “average” dose little predictability for those doing the administering. Accurate pediatric medication administration requires knowledge of the child’s precise weight; proper conversion of pounds to kilograms; the correct choice of appropriate preparations and concentrations; and the ability to measure and administer doses properly, particularly for liquid medications. An inpatient study covering all types of medications carried out at two urban teaching hospitals reported a rate of medication order errors of 4.2 percent, or 405 prescribing errors per 1,000 pediatric patients (Kaushal et al., 2001). Using a broader definition of medication error, a French study reported a higher rate—24.0 percent (Fontan et al., 2003). Also using a broader definition, a still higher rate was observed in a pediatric ICU—30.0 percent (Potts et al., 2004). Rates of administration errors were estimated to be 0.72 per 100 orders (or 7.0 per 100 admissions, or 19.8 per 1,000 patient days) for all types of medication in a pediatric inpatient setting (Kaushal et al., 2001) and 23.0 per 100 opportunities for error in a pediatric nephrology ward (Fontan et al., 2003). There have been two pediatric emergency department studies. One of these, conducted in a Canadian hospital, estimated that 100.0 prescribing

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Preventing Medication Errors TABLE 3-5 Errors in Hospital Pediatric Care Medication ordering errors Percentage of prescriptions containing an error 4.2 (Kaushal et al., 2001) 24 (Fontan et al., 2003) Medication ordering errors in pediatric intensive care Percentage of prescriptions containing an error 30 (Potts et al., 2004) Administration errors Per 100 orders 0.72 (Kaushal et al., 2001) Administration errors in pediatric nephrology units Per 100 opportunities for error 23 (Fontan et al., 2003) Emergency department prescribing errors Per 1,000 patients 100 (Kozer et al., 2002) Emergency department administration errors Per 1,000 patients 39 (Kozer et al., 2002) Emergency department acetaminophen doses ordered outside recommended range Per 100 doses ordered 22 (Losek, 2004) errors and 39.0 administration errors occurred in the emergency department per 1,000 pediatric patients (Kozer et al., 2002). The other study found that 22.0 percent of acetaminophen doses ordered were outside the recommended 10–15 milligrams/kilogram recommendation for these patients (Losek, 2004). (See Table 3-5 for a summary of errors in hospital pediatric care). Finally, a recent study found that potential medication errors occur frequently in outpatient pediatric clinics (McPhillips et al., 2005). In a sample of new prescriptions for 22 common medications, approximately 15 percent of children were dispensed a medication with a potential dosing error. Psychiatric Care Many studies of medication errors associated with psychotropic medications either were conducted as part of larger general medical–surgical studies or other ADE-reporting databases, or were restricted to geriatric populations in nonpsychiatric restricted settings, such as nursing homes and ambulatory clinics. The one major study devoted exclusively to medication errors in psychiatric care found a very high rate of errors in a state

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Preventing Medication Errors 450,000; these are likely underestimates given the higher rates of another study (Jha et al., 1998). There is one estimate of the extra costs of inpatient care for a preventable ADE—$5,857 (Bates et al., 1997); this figure excludes health care costs outside the hospital and is derived from 1993 cost data. Assuming conservatively an annual incidence of 400,000 preventable ADEs, each incurring extra hospital costs of $5,857, gives a total cost of $2.3 billion (1993 dollars) or $3.5 billion8 (2006 dollars). Long-term care—Gurwitz and colleagues (2005) projected an annual incidence of 800,000 preventable ADEs—again likely an underestimate given the higher ADE rates of earlier studies (Gerety et al., 1993; Cooper, 1999). However, there is no estimate of the health care costs for this group of preventable ADEs. Ambulatory care—The best estimate derives from a study (Field et al., 2005) of the costs of ADEs in older adults, which estimated the annual cost of preventable ADEs for all Medicare enrollees aged 65 and older. The cost per preventable ADE was $1,983, and the national annual costs were estimated to be $887 million in 2000. These figures include the costs of inpatient stays (62 percent of the total cost), emergency department visits (6 percent), outpatient care and physician fees (28 percent), and prescribed medicines (4 percent). The national estimate is almost certainly conservative because the detection approach used did not include direct patient contact, which identifies many more ADEs than other approaches. In addition to the likelihood of being underestimates, the above estimates have some important omissions. First, the costs of some highly common medication errors, such as drug use without a medically valid indication and failure to receive drugs that should have been prescribed, were excluded from the Medicare study of ambulatory ADEs (Field et al., 2005). Moreover, the costs of morbidity and mortality arising from the lack of adherence to the drug regimen were not assessed. Second, all the cost studies omitted other important costs—lost earnings, the costs of not being able to carry out household duties (lost household production), and compensation for pain and suffering. Third, few data are available for any setting regarding the costs of medication errors that do not result in harm. While no injury is involved, these errors often create extra work, and the costs involved may be substantial. For example, one estimate suggested that a 700-bed hospital has 300,000 medication errors per year, each of which creates approximately 20 minutes of extra work for providers—mainly nurses and pharmacists (Bates et al., 1995a). Near-misses may also cost 8 The producer price index for general medical and surgical hospitals increased by 49.4 percent between 1993 and 2006 (BLS, 2006).

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Preventing Medication Errors more than medication errors with little potential for harm, although this possibility has not been assessed formally. Limited Understanding of the Costs of Medication Errors Very few studies have examined the costs of medication errors in individual care settings; rather, studies have focused mainly on the additional hospital costs of ADEs. One study (Bates et al., 1997) used cost data that are now more than 10 years old. There has been one study of the health care costs of treating preventable ADEs occurring in ambulatory care. There are large gaps in our understanding of the costs of medication errors. No studies have been conducted on (1) the costs of medication errors in pediatric and psychiatric care, (2) the costs associated with errors involving OTC and complementary and alternative medications, (3) the costs of medication errors not considered ADEs, (4) the costs of the failure to receive drugs that should have been prescribed, (5) the costs of over-utilization of drugs (for example, antibiotics), and (6) the costs associated with nonadherence to prescribed drugs in the ambulatory setting. Finally, we have limited understanding of the economic and social costs of medication errors borne by patients and their families. CONCLUSION On the basis of the information currently available about the various types of medication errors, the committee acknowledges that it is impossible to formulate a fully comprehensive set of corrective medication error strategies. For example, there is a need to better define the impact on the incidence of errors in the medication-use stage of system problems in the research and development, regulatory review, and distribution/marketing stages (for example, inadequate information about dosages for special populations, look-alike/sound-alike drug names). In addition, the impact of underutilization of medications for the treatment of acute coronary syndromes, for antibiotic prophylaxis, and for thrombosis prophylaxis is not well understood. The area best understood is the incidence of preventable ADEs in various care settings—especially in the hospital, but also in nursing homes and in ambulatory care for adults—where significant problems and their causes have been identified. More research is needed to evaluate the impact of upstream problems on the incidence of errors in the use of medications, as well as the impact of the underutilization of medications.

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