BOX 5-6

Detection Methods for Medication Errors and ADEs

  • Attendance at medical rounds or review of nurse change-of-shift reports to look for clues that an error has occurred (Andrews et al., 1997; Baker, 1997)

  • Chart review (Bates et al., 1995a,b)

  • Comparison of drugs removed from an automated drug dispensing device with physician orders (Shuttleworth and Ruelle, 1996)

  • Computerized analysis to identify patients receiving target drugs that may be used to treat a medication error or a search for serum drug concentration orders that may indicate an overdose (Bates et al., 1995b)

  • Direct observation for detecting medication administration errors (Allan and Barker, 1990; Barker et al., 2002)

  • Monitoring of doses returned to the pharmacy (indicating possible dose omissions) (Gift et al., 1996)

  • Examination of death certificates (Phillips et al., 1998)

  • Comparison of medication administration records with physician orders (Cunningham et al., 1996)

  • Voluntary reports of medication errors (Phillips, 2002)

  • Stimulated self-reports using interviews (Bates et al., 1995a,b)

  • Urine testing as evidence of omitted drugs and unauthorized drug administration (Ballinger et al., 1974)

Accurate counting of medication errors and ADEs using appropriate detection methods is now possible and is critical for establishing the scope of the error problem. Accurate counts also enable providers to assess the impact of error prevention efforts. The discussion in this section focuses on what health care providers can do to improve medication safety through the use of error detection and monitoring techniques; the use of external reporting programs for safety improvement, introduced in Chapter 2, is discussed in Chapter 8.

Many health care systems monitor medication errors by tracking self-reported errors. Experts generally acknowledge that such reports detect a small percentage of the true number of errors and ADEs, but they believe this approach is the only feasible option. There are, however, better methods for counting errors. The goal of the committee’s recommendation in this area is to assist health care providers in selecting improved methods for monitoring of medication errors and ADEs while maintaining the recognized benefits of current reporting mechanisms.

Numerous detection methods for medication errors and ADEs have been employed (see Box 5-6). The selection of a method for inpatient settings can be facilitated by answers to the following questions:

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