The purpose of this study was (1) to determine frequency and type of medication errors (MEs), (2) to assess the number of MEs prevented by registered nurses, (3) to assess the consequences of ME for patients, and (4) to compare the number of MEs reported by a newly developed medication error self-reporting tool to the number reported by the traditional incident reporting system. We conducted a cross-sectional study on ME in the Cardiovascular Surgery Department of Bern University Hospital in Switzerland. Eligible registered nurses ( ) involving in the medication process were included. Data on ME were collected using an investigator-developed medication error self reporting tool (MESRT) that asked about the occurrence and characteristics of ME. Registered nurses were instructed to complete a MESRT at the end of each shift even if there was no ME. All MESRTs were completed anonymously. During the one-month study period, a total of 987 MESRTs were returned. Of the 987 completed MESRTs, 288 (29%) indicated that there had been an ME. Registered nurses reported preventing 49 (5%) MEs. Overall, eight (2.8%) MEs had patient consequences. The high response rate suggests that this new method may be a very effective approach to detect, report, and describe ME in hospitals. 1. Introduction Adverse events (AEs) caused by medication errors (MEs) continue to be one of the great challenges in acute care settings. Recent data suggest that each year more than 1.5 million patients are harmed by ME in the United States [1]. A substantial body of evidence confirms the risk resulting from ME [2–6]. According to the report “Preventing Medication Errors,” ME affect approximately 5% to 10% of patients in the United States and cause more than 7000 deaths annually [1]. The definition of ME remains inconsistent although attempts to develop an international definition have been made [7]. The National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) states that “A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; use” [8]. Studies conducted in various healthcare settings report medication error rates between 19–70%, depending on
References
[1]
P. Aspden, I. Institute of Medicine, Committee on, and E. Preventing Medication, Preventing Medication Errors, National Academies Press, 2007.
[2]
D. W. Bates, D. J. Cullen, N. Laird et al., “Incidence of adverse drug events and potential adverse drug events: implications for prevention,” Journal of the American Medical Association, vol. 274, no. 1, pp. 29–34, 1995.
[3]
D. W. Bates, L. L. Leape, and S. Petrycki, “Incidence and preventability of adverse drug events in hospitalized adults,” Journal of General Internal Medicine, vol. 8, no. 6, pp. 289–294, 1993.
[4]
D. W. Bates, E. B. Miller, D. J. Cullen, et al., “Patient risk factors for adverse drug events in hospitalized patients. ADE Prevention Study Group,” Archives of Internal Medicine, vol. 159, no. 21, pp. 2553–2560, 1999.
[5]
L. L. Leape, “Preventing adverse drug events,” American Journal of Health-System Pharmacy, vol. 52, no. 4, pp. 379–382, 1995.
[6]
L. L. Leape, T. A. Brennan, N. Laird et al., “The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II,” The New England Journal of Medicine, vol. 324, no. 6, pp. 377–384, 1991.
[7]
M. Lisby, L. P. Nielsen, B. Brock, and J. Mainz, “How are medication errors defined? A systematic literature review of definitions and characteristics,” International Journal for Quality in Health Care, vol. 22, no. 6, pp. 507–518, 2010.
[8]
NCCMERP, National Coordinating Council for Medication Error Reporting and Prevention, About Medication Errors: What is a Medication Error?, 2012, http://www.nccmerp.org/aboutMedErrors.html.
[9]
A. Valentin, M. Capuzzo, B. Guidet et al., “Errors in administration of parenteral drugs in intensive care units: multinational prospective study,” British Medical Journal, vol. 338, Article ID b814, 2009.
[10]
J. I. Westbrook, M. Reckmann, L. Li, et al., “Effects of two commercial electronic prescribing systems on prescribing error rates in hospital in-patients: a before and after study,” PLoS Medicine, vol. 9, no. 1, Article ID e1001164, 2012.
[11]
J. I. Westbrook, M. I. Rob, A. Woods, and D. Parry, “Errors in the administration of intravenous medications in hospital and the role of correct procedures and nurse experience,” BMJ Quality & Safety, vol. 20, no. 12, pp. 1027–1034, 2011.
[12]
H. H. Hoefel, L. Lautert, C. Schmitt, T. Soares, and S. Jordan, “Vancomycin administration: mistakes made by nursing staff,” Nursing Standard, vol. 22, no. 39, pp. 35–42, 2008.
[13]
E. N. de Vries, M. A. Ramrattan, S. M. Smorenburg, D. J. Gouma, and M. A. Boermeester, “The incidence and nature of in-hospital adverse events: a systematic review,” Quality and Safety in Health Care, vol. 17, no. 3, pp. 216–223, 2008.
[14]
J. A. Cafazzo, P. L. Trbovich, A. Cassano-Piche et al., “Human factors perspectives on a systemic approach to ensuring a safer medication delivery process,” Healthcare Quarterly, vol. 12, pp. 70–74, 2009.
[15]
L. L. Leape, D. W. Bates, D.J. Cullen, et al., “Systems analysis of adverse drug events. ADE Prevention Study Group,” Journal of the American Medical Association, vol. 274, no. 1, pp. 35–43, 1995.
[16]
K. N. Barker, E. A. Flynn, G. A. Pepper, D. W. Bates, and R. L. Mikeal, “Medication errors observed in 36 health care facilities,” Archives of Internal Medicine, vol. 162, no. 16, pp. 1897–1903, 2002.
[17]
N. M. LaPointe and J. G. Jollis, “Medication errors in hospitalized cardiovascular patients,” Archives of Internal Medicine, vol. 163, no. 12, pp. 1461–1466, 2003.
[18]
R. E. Ferner, “The epidemiology of medication errors: the methodological difficulties,” British Journal of Clinical Pharmacology, vol. 67, no. 6, pp. 614–620, 2009.
[19]
E. J. Thomas and L. A. Petersen, “Measuring errors and adverse events in health care,” Journal of General Internal Medicine, vol. 18, no. 1, pp. 61–67, 2003.
[20]
C. Meyer-Massetti, C. M. Cheng, D. L. B. Schwappach et al., “Systematic review of medication safety assessment methods,” American Journal of Health-System Pharmacy, vol. 68, no. 3, pp. 227–240, 2011.
[21]
R. E. Ferner and J. K. Aronson, “National differences in publishing papers on adverse drug reactions,” British Journal of Clinical Pharmacology, vol. 59, no. 1, pp. 108–111, 2005.
[22]
J. M. Naessens, C. R. Campbell, J. M. Huddleston et al., “A comparison of hospital adverse events identified by three widely used detection methods,” International Journal for Quality in Health Care, vol. 21, no. 4, pp. 301–307, 2009.
[23]
D. Dunn, “Incident reports—their purpose and scope,” AORN Journal, vol. 78, no. 1, pp. 46–66, 2003.
[24]
D. F. Polit, C. T. Beck, and S. V. Owen, “Focus on research methods: is the CVI an acceptable indicator of content validity? Appraisal and recommendations,” Research in Nursing and Health, vol. 30, no. 4, pp. 459–467, 2007.
[25]
E. Ammenwerth, P. Schnell-Inderst, C. Machan, and U. Siebert, “The effect of electronic prescribing on medication errors and adverse drug events: a Systematic review,” Journal of the American Medical Informatics Association, vol. 15, no. 5, pp. 585–600, 2008.
[26]
D. W. Bates, L. L. Leape, D. J. Cullen et al., “Effect of computerized physician order entry and a team intervention on prevention of serious medication errors,” Journal of the American Medical Association, vol. 280, no. 15, pp. 1311–1316, 1998.
[27]
D. J. Cullen, D. W. Bates, and L. L. Leape, “Prevention of adverse drug events: a decade of progress in patient safety,” Journal of Clinical Anesthesia, vol. 12, no. 8, pp. 600–614, 2000.
[28]
E. G. Poon, C. A. Keohane, R. N. Catherine, et al., “Effect of bar-code technology on the safety of medication administration,” The New England Journal of Medicine, vol. 362, no. 18, pp. 1698–1707, 2010.
[29]
E. A. Flynn, K. Barker, and B. Barker, “Medication-administration errors in an emergency department,” American Journal of Health-System Pharmacy, vol. 67, no. 5, pp. 347–348, 2010.
[30]
B. Hardmeier, S. Braunschweig, M. Cavallaro et al., “Adverse drug events caused by medication errors in medical inpatients,” Swiss Medical Weekly, vol. 134, no. 45-46, pp. 664–670, 2004.
[31]
J. K. Aronson, “Medication errors: definitions and classification,” British Journal of Clinical Pharmacology, vol. 67, no. 6, pp. 599–604, 2009.
[32]
V. A. Kellogg and D. S. Havens, “The Shift Coupon: an innovative method to monitor adverse events,” Journal of Nursing Care Quality, vol. 21, no. 1, pp. 49–55, 2006.
[33]
D. J. Cullen, D. W. Bates, S. D. Small, J. B. Cooper, A. R. Nemeskal, and L. L. Leape, “The incident reporting system does not detect adverse drug events: a problem for quality improvement,” The Joint Commission Journal on Quality Improvement, vol. 21, no. 10, pp. 541–548, 1995.
[34]
A. Agrawal, “Medication errors: prevention using information technology systems,” British Journal of Clinical Pharmacology, vol. 67, no. 6, pp. 681–686, 2009.
[35]
L. L. Leape, “Who's to blame?” Joint Commission Journal on Quality and Patient Safety, vol. 36, no. 4, pp. 150–151, 2010.
[36]
L. L. Leape and D. M. Berwick, “Safe health care: are we up to it?” British Medical Journal, vol. 320, no. 7237, pp. 725–726, 2000.
[37]
L. L. Leape, G. Rogers, D. Hanna et al., “Developing and implementing new safe practices: voluntary adoption through statewide collaboratives,” Quality and Safety in Health Care, vol. 15, no. 4, pp. 289–295, 2006.
[38]
L. L. Leape, D. S. Swankin, and M. R. Yessian, “A conversation on medical injury,” Public Health Reports, vol. 114, no. 4, pp. 302–317, 1999.
[39]
R. Flin, C. Burns, K. Mearns, S. Yule, and E. M. Robertson, “Measuring safety climate in health care,” Quality and Safety in Health Care, vol. 15, no. 2, pp. 109–115, 2006.