Abstract
Objective. The purpose of this study was to record prospectively the frequency of medication order errors in a general hospital in Israel with the objective of assessing the impact of pharmacist intervention in preventing potential harm.Methods. The study was conducted during a 6‐month period. A total of 160 medication order errors were detected at the hospital of which 60.6% were prescription errors and 39.4% were therapy ones. Principal types of errors detected were incorrect dosage (27.5%), interactions between drugs (20%), incorrect drug (12.5%), route (11.2%) and frequency (11.2%). Medication error rate by degree of severity was calculated per 100 patient days. The highest rate was found in Hemato‐Oncology (2.48), followed by Intensive Care (0.82), Surgery (0.48) and Internal Medicine (0.26). Anti‐infective drugs were the most prevalent class of drugs in which errors occurred (38.7%) followed by total parenteral nutrition preparations (21.8%), antineoplastics (15.6%) and anticoagulants (11.3%). Changes in medication orders due to pharmacists' intervention only occurred in 73.8% of error cases, most referring to dosage or route change (37.5%).Conclusion. This study underestimates the actual number of medication errors. However, it identified problem areas and trends so that better measures to improve drug use could be implemented.
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References
Lesar TS, Lomaestro BM, Pohl H. Medication – prescribing errors in a teaching hospital. A 9-year experience. Arch Intern Med 1997;157:1569–76.
Folli HL, Poole RL, Benitz WE, Russo JC. Medication error prevention by clinical pharmacists in two children's hospitals. Pediatrics 1987,79:718–22.
Lesar TS, Briceland LL Delcoure K, et al. Medication prescribing errors in a teaching hospital. JAMA 1990,263:2329–34.
Peterson CD, Goldberg DE. Pharmacy coordinated process for evaluating physician drug prescribing. Am J Hosp Pharm 1989;46:1787–91.
Thorn DB, Sexton MG, Lemay AP, Sarigianis JS, Melita DD, Gustafson NJ. Effect of a cancer chemotherapy prescription form on prescription completeness. Am J Hosp Pharm 1989;46:1802–6.
Lacasa C, Cot R, Martinez J, Polo C, Andreu C, Serrais J, Sala P. Medication errors in a general hospital. Environ Health Perspect 1998;4:35–40.
Leape LL, Lawthers AG, Brennan TA, Johnson WG. Preventing medical injury. Qual Rev Bull 1993;19:144–9.
Leape LL. Error in medicine. JAMA 1994;272:1851–7.
Bates DW, Gullen D, Laird N. et al. Incidence of adverse drug events and potential adverse drug events: implications for prevention. JAMA 1995;274: 29–34.
Leape LL, Bates DW, Cullen DJ, et al. System Analysis of adverse drug events. JAMA 1995;274:35–43.
Andrews LB, Stocking C, Krizec T, Gotlieb L, et al. An alternative strategy for studying adverse events in medical care. Lancet 1997;349:309–13.
Brennan TA, Leape LL, Laird N, et al. Incidence of adverse effects and negligence in hospitalized patients: Results of the Harvard Medical Practice Study. I. N Engl J Med 1991;324:370–6.
Leape LL, Brennan TA, Laird N, et al. The nature of adverse events in hospitalized patients: Results of the Harvard Medical Practice Study. II. N Engl J Med 1991;324:377–84.
Classen DC, Pestotnik SL, Evans RS, et al. Adverse drug events in hospitalized patients. Excess length of stay, extra costs and attributable mortality. JAMA 1997;277:301–6.
Lesar TS, Briceland L, Stein DS. Factors related to errors in medication prescribing. JAMA 1997;277:312–7.
Stephens D. Insurer looks at the pharmacist's cost control function. Am Druggist 1991;203:62.
Dobie RL, Rascati KL. Documenting the value of pharmacist interventions. Am Pharmacy 1994;34:50–4.
Porsius AJ, Van Den Brick G. Quality assessment of drug therapy: Criteria and protocols. Pharm Weekbl.1991;126/49–50:1275-82.
Bates DW, Spell N, Cullen DJ, et al. The cost of adverse drug events in hospitalized patients. Adverse drug events prevention study group. JAMA 1997; 277;307–11.
Rupp MT. Value of community pharmacists' interventions to correct prescribing errors. Ann Pharmacother 1992;26:1580–4.
Vincer MJ, Murrey JM, Yull A, Allen AC, Evane JR, Stineon DA. Drug error and incidence in a neonatal care unit: a quality assurance activity. Am J D C 1989;143:740–87.
O'Donnell J. Pharmacy malpractice: An avoidable hospital cost. Perspect Pharmacol 1984;1:1–12.
Hartwig SC, Denger SD, Schneider PJ. Severity indexed, incident report based medication error reporting program. Am J Hosp Pharm 1991;48:2611–6.
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Lustig, A. Medication error prevention by pharmacists ‐ An Israeli solution. Pharm World Sci 22, 21–25 (2000). https://doi.org/10.1023/A:1008774206261
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DOI: https://doi.org/10.1023/A:1008774206261