A 3-year study of medication incidents in an acute general hospital.
J Clin Pharm Ther. 2008 Apr;33(2):109-14
Authors: Song L, Chui WC, Lau CP, Cheung BM
BACKGROUND AND OBJECTIVE: Inappropriate medication use may harm patients. We analysed medication incident reports (MIRs) as part of the feedback loop for quality assurance. METHODS: From all MIRs in a university-affiliated acute general hospital in Hong Kong in the period January 2004-December 2006, we analysed the time, nature, source and severity of medication errors. RESULTS: There were 1278 MIRs with 36 (range 15-107) MIRs per month on average. The number of MIRs fell from 649 in 2004, to 353 in 2005, and to 276 in 2006. The most common type was wrong strength/dosage (36.5%), followed by wrong drug (16.7%), wrong frequency (7.7%), wrong formulation (7.0%), wrong patient (6.9%) and wrong instruction (3.1%). 60.9%, 53.7% and 84.0% of MIRs arose from handwritten prescription (HP) rather than the computerized medication order entry in 2004, 2005 and 2006 respectively. In 43.1% of MIRs, preregistration house officers were involved. Most errors (80.2%) were detected before any drug was wrongly administered. The medications were administered in 212 cases (19.7%), which resulted in an untoward effect in nine cases (0.8%). CONCLUSIONS: The most common errors were wrong dosage and wrong drug. Many incidents involved preregistration house officers and HPs. Our computerized systems appeared to reduce medication incidents.
PMID: 18315775 [PubMed - indexed for MEDLINE]