US Hospitals Repeat Same Medication Errors: Report

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US Hospitals Repeat Same Medication Errors: Report
Tue May 21, 2:34 PM ET
By Karen Pallarito

NEW YORK (Reuters Health) - While US hospitals and health systems are doing a better job of reporting medication mistakes, they continue to make the same errors over and over, according to findings released Monday by the US Pharmacopeia (USP), a national standards-setting organization.


The report shows no improvement between 1999 and 2000 in the overall percentage of reported medication errors that ended in patients being harmed or dying. In 2000, 3% of the 41,296 errors reported to USP's drug-errors tracking program resulted in patient harm. The rate in 1999, based on a smaller sample of reporting facilities and reported errors, was also 3%.

The three leading causes of drug errors also were unchanged. "Omission errors" topped the list, suggesting that patients still may not be getting the drugs they need, according to USP. And when patients do receive their medications, they may be getting the wrong dose or quantity, or the wrong drug entirely, it noted.

Less than 1% of reported errors resulted in patient death, the report indicates.

USP, based in Rockville, Maryland, was encouraged by the increase in hospital participation in 2000. The number of providers voluntarily reporting mistakes to the USP medical errors database, called MedMARx, increased threefold to 184, while the number of reports jumped sevenfold to 41,296.

However, because the analysis is based on the errors that participating hospitals report to MedMARx, it is impossible to know whether the actual rate of medication errors has worsened, said Diane D. Cousins, USP's vice president of practitioner and product experience.

Yet it does serve as a "call to action" by highlighting those areas that remain consistently troublesome, she told Reuters Health. USP officials were surprised that there were so many similarities in the data for 1999 and 2000.

Insulin, heparin and morphine, for example, were frequently associated with medication errors in both years. The reasons, through, are less obvious.

It could be that drugs like heparin are used more often and therefore are associated with a greater incidence of medication errors, Cousins suggested. On the other hand, it could be that the protocols for using such drugs are more complicated and more prone to mishaps.

Dr. Don Nielsen, senior vice president for quality leadership at the American Hospital Association (AHA), noted that only a small percentage of the nation's roughly 5,000 hospitals are represented in the MedMARx database. He also pointed out that the latest data were collected just after the Institute of Medicine (news - web sites) (IOM) issued its landmark report on medical and medication errors.

While the IOM report helped focus attention on the issue, Nielson suggested that it would be unreasonable "to expect change between 1999 and 2000." Hospitals, he added, are more aware of what needs to be improved, but "it's unfortunately not an overnight process."

In an effort to reduce medication errors, the AHA is working with the Institute for Safe Medication Practices to develop tools that hospitals may use to identify problems and improve processes.

If there is one thing that Cousins is certain of, it's that there is no "silver bullet" to resolve the incidence of medication errors at US hospitals. It will require action by payers, providers, regulators and other stakeholders, she said. "The solution is going to have to be a coordinated, inter-organizational, multidiscipline approach."