The following HTML text is provided to enhance online
readability. Many aspects of typography translate only awkwardly to HTML.
Please use the page image
as the authoritative form to ensure accuracy.
Preventing Medication Errors
In the subset of studies that evaluated preventable ADEs, prescription errors associated with patient injuries ranged from 3.7 to 84.1 per 1,000 admissions (Bates et al., 1995b; Hardmeier et al., 2004; Nebeker et al., 2005).
Preparation and Dispensing of the Drug
Preparation and dispensing errors occurred at a rate of 2.6 per 1,000 admissions in a tertiary care hospital in Florida (Winterstein et al., 2004) (see Table C-2).
Two studies focused exclusively on intravenous (IV) medications. One study, at one U.K. and two German hospitals, found a rate of preparation errors of 26 percent per observed preparation (88 preparation errors out of 337 observations) (Wirtz et al., 2003). The other study, at a tertiary and a community hospital in the United Kingdom, found a rate of preparation errors of 49 percent per observed preparation (212 preparation and administration errors out of 430 doses) (Taxis and Barber, 2003).
Preparation and dispensing errors were associated with preventable ADEs at rates of 0.6 per 1,000 admissions in a Swiss study of 6,383 patients (Hardmeier et al., 2004); 1.1 per 1,000 admissions in a study of 4,031 patients at two tertiary hospitals in Boston, Massachusetts (Bates et al., 1995b); and 1.6 per 1,000 admissions in a study of 937 admissions at a tertiary hospital in Salt Lake City, Utah (Nebeker et al., 2005).
Administration of the Drug
As with prescribing error rates, rates of administration errors varied widely in medical and surgical units (See Table C-3). Rates per opportunity
TABLE C-2 Hospital Care: Preparation and Dispensing Errors
Error rates: general medications
Per 1,000 admissions—detection method
2.6 (Winterstein et al., 2004)—prompted reports
Error rates: intravenous (IV) medications
Per preparation—detection method
26 percent (Wirtz et al., 2003) (U.K. and German study)—direct observation
49 percent (Taxis and Barber, 2003) (U.K. study)—direct observation
Preventable ADEs
Per 1,000 admissions—detection method
0.6 (Hardmeier et al., 2004) (Swiss study)—chart review
1.1 (Bates et al., 1995b)—prompted reporting, chart review
1.4 (Nebeker et al., 2005)—review of electronic medical record