Summary of studies with overall medication error results
| Citation | Numerator and numerator description | Denominator and denominator description |
|---|---|---|
| ADE, adverse drug event; DT, diphtheria and tetanus toxoids vaccine; DTP, diphtheria and tetanus toxoids and cellular pertussis vaccine; FDA, Food and Drug Administration; IM, intramuscularly; MAR, medication administration record; MedMARx, United States Pharmacopeia database designed to reduce medication errors in hospitals; OPV, oral polio vaccine given; PICU, paediatric intensive care unit; USP, United States Pharmacopeia. | ||
| *Potential ADE defined as having the potential to produce significant injury, includes errors detected before drug administration as well as errors that did not produce significant adverse consequences, excludes errors that were identified and corrected before the drug was entered into MAR. | ||
| †ICD9, International Classification of Disease, 9th edition. Public Health Service and Health Care Financing Administration. International classification of diseases, 9th revision, clinical modification. Vols 1, 2, and 3; eighth edition. Washington, DC: Public Health Service; 1997. | ||
| ‡Code 995.2: adverse effect/allergic reaction/hypersensitivity/idiosyncrasy of drug, medicinal and biological substance (due) to correct medicinal substance properly administered. | ||
| Simpson et al23 | 24.1 Mean monthly medication errors, includes prescribing and administration errors | Per 1000 neonatal activity days, recorded over 3 months |
| Petridou et al25 | 11 Estimated incidence of errors in prescribing, dispensing, administering immunisations based on assumption of 100 000 children born in Greece each year and each child gets 10 immunisations: from National Poison Control Registry with estimated 47 000 calls a year over 2 year period | Per 1 000 000 immunisation doses, recorded over 2 years |
| 40 Immunisation errors reported from National Poison Control Registry 12 Wrong route (eg OPV given IM¶ errors reported from National Poison Control Registry 13 Overdose errors reported from National Poison Control Registry 6 DTP instead of DT administered errors reported from National Poison Control Registry 3 Expired vaccine errors reported from National Poison Control Registry 7 Extra dose errors reported from National Poison Control Registry | 47 000 Estimated calls a year, recorded over 2 years | |
| Cimino et al28 | 3259 Orders with errors 1335 Orders with errors excluding missing date/time only 1924 Orders with only time/date errors 16 Preventable ADEs 2249 Low ADE potential (missing information only) | 12 026 Manual PICU orders in 2 weeks |
| Potts et al30 | 147 Potential ADEs*: includes duplicate treatment, inappropriate dose/interval/route, wrong drug, allergy, drug interaction, wrong units 466 Rule violations: includes trailing zeros, abbreviations 2662 Potential ADEs*, medication prescribing errors and rule violations | 6803 Manual PICU orders in 2 months |
| Sangtawesin et al31 | 322 Medication errors | 32 105 Admissions in 14 months |
| Holdsworth et al35 | 46 Preventable ADEs: preventable as determined by authors 94 Potential ADEs* | 1197 Admissions in 8 months |
| 46 Preventable ADEs as defined above 94 Potential ADEs* as defined above | 10 164 Patient days in 8 months | |
| Frey et al38 | 253 Prescription, dispensing and administering errors 93 Dose too high errors, either prescribed, dispensed or administered 55 Drug omitted errors, either prescribed, dispensed or administered 39 Dose too low errors, either prescribed, dispensed or administered 34 Wrong route errors, either prescribed, dispensed or administered 32 Wrong drug errors, either prescribed, dispensed or administered | 275 Error reports in 2001 |
| Butte et al41 | 206 Patients with at least one invalid immunisation | 580 Charts reviewed in 3 months |
| 289 Invalid doses: dose given before minimum recommended age, doses given within the recommended spacing from previous dose, dose given unnecessarily (this means 1 year earlier than required age), live virus vaccine given to close to previous live virus vaccine 98 Invalid doses because given before recommended age 2 Invalid doses because given too close to live virus dose 96 Invalid doses because unnecessary extra dose 105 Invalid doses because too close to previous dose 12 Invalid doses because too young and too close to previous dose | 6983 Immunisation doses given in 3 months | |
| Kaushal et al42 | 616 Medication errors defined as errors in drug ordering, transcribing, dispensing, administering or monitoring 115 Potential ADEs* defined as errors with significant potential for injuring patient 5 Preventable ADEs* defined as ADE* associated with medication error 337 IV medication errors 126 Oral medication errors 46 Inhalation medication errors | 10 778 Orders, 1120 admissions and 3932 patient days in 6 weeks |
| Marino et al43 | 784 Medication errors | 3312 Orders in summer 1995 11 978 Doses in summer 1995 669 Patient days in summer 1995 |
| Cote et al45 | 38 Drug overdoses or local anaesthetic overdoses submitted to the FDA’s incident reporting system, cases from USP and case reports from paediatric anaesthesiologists, intensivists, and paediatric emergency medicine specialists 9 Prescribing/transcribing errors as described above | 95 ADE reports for sedations from 1969 to March, 1996 as described in numerator |
| Upperman et al47 | 0.3 ADEs | Per 1000 doses, recorded over 9 months |
| Cowley et al48 | 543 Omission reports submitted to MedMARx database 494 Wrong dose/quantity reports submitted to MedMARx database 253 Wrong time reports submitted to MedMARx database | 2003 Paediatric errors submitted in 2 years |
| Slonim et al50 | 0.13 1988 drug errors based on reported ICD9† code 995.2‡. All results are national estimates, no real numerator and denominator stated 0.09 1991 drug errors as described above 0.07 1994 drug errors as described above 0.03 1997 drug errors as described above | Per 100 paediatric admissions reported nationally |