Original Contribution
Medication prescribing errors in the prehospital setting and in the ED

https://doi.org/10.1016/j.ajem.2011.04.023Get rights and content

Abstract

Background

Medication errors are a common cause of iatrogenic adverse drug events. The incidence and nature of medication errors during prehospital treatment have not been fully described.

Objectives

The objectives of this study are to describe the incidence and characteristics of medication errors in adults during prehospital emergency treatment and in the emergency department (ED) and to identify risk factors for medication errors in those settings.

Methods

This is a retrospective study of adult patients transferred by emergency medical services to the ED of a university-affiliated hospital in Israel. The drugs administered in the mobile intensive care unit and in the ED were reviewed by 2 reviewers, who independently decided whether an error had occurred. The primary outcome was the number of drug errors per patient. Secondary outcomes were the type and severity of the errors and variables associated with increased incidence of drug errors.

Results

During the study period, 1837 patients were brought to the ED by mobile intensive care unit vehicles. Five hundred thirty-six patient charts (29%) were randomly selected for review; 65 charts (12.12%) could not be found; thus, 471 charts were reviewed. In the emergency vehicle, 188 patients (45.63%) received medications; of those, 12.76% (24 patients) were subject to a medication error. The number of drugs administered and long evacuation times were associated with higher risk for an error (P < .01 and P = .011, respectively). The presence of a physician in the emergency vehicle did not alter the risk of an error (P = .95). In the ED, 332 patients (72.6%) received medications. Of those, medication errors occurred in 120 patients (36.1%). The more medications administered, the higher the risk of error (P < .01). Less errors occurred in trauma patients (P = .041).

Conclusion

More medication errors occur in the ED than in the emergency vehicles. Patients treated with multiple medications are more prone to medication errors.

Introduction

Medication errors are a common cause of iatrogenic adverse events [1]. They can lead to severe morbidity, prolonged hospital stay, unnecessary diagnostic tests, unnecessary treatments, and death [2], [3]. Medication errors have been estimated to harm 1% to 2% of patients admitted to UK and US hospitals [4], [5]—most attributable to prescribing errors [2], [6], [7].

Preventable errors are significantly more common in the emergency and intensive care units than in any other hospital departments [1], [8]. In the emergency department (ED), the lack of continuity of patient care, coupled with an inadequate information infrastructure for care across the continuum, often forces emergency providers to see patients without all the information needed to make well-informed decisions [9], [10].

In a prospective observational study conducted in a tertiary care ED by Patanwala et al [11], 1 or more medication errors were found in almost 60% of the patients. In 37% of the cases, an error affected the patients; but only 1 error resulted in patient harm.

Resuscitation is an extremely stressful and uncontrolled situation for the medical staff. The physician must respond promptly to the needs of an unstable patient for whom often very limited information is available. In a study on medication errors during pediatric mock resuscitations, medication errors were found in 7 of 8 mock resuscitations [12].

Data on the incidence and nature of medication errors during prehospital treatment and transport are limited. In a survey among paramedics in San Diego, 9% of the paramedics reported medication errors [13].

We hypothesized that because of the lack of adequate time, together with the far from ideal conditions in the emergency medical services (EMS) setting, the rate of medication errors in the EMS setting is likely to be higher than in the ED. The objectives of the current study were to describe the incidence and characteristics of medication errors during prehospital treatment and to compare it with the incidence of errors in the ED.

Section snippets

Design

This is a retrospective chart review of adult patients transferred by EMS to a large teaching hospital in Israel.

Setting

Magen David Adom is the largest EMS service in Israel and provides most prehospital EMS services in Israel. Mobile intensive care unit (MICU) ambulances are equipped with medications and staffed with either paramedics or a physician. The staff is capable of providing advanced life support.

Assaf Harofeh is a large university-affiliated hospital in central Israel, serving a population

Results

One thousand eight hundred thirty-seven patients were brought to Assaf Harofe ED by an emergency vehicle during 2007. Five hundred thirty-six patient charts (29%) were randomly selected for review. Sixty-five charts (12.12%) could not be found; thus, 471 remaining charts were included in our study. In 59 charts, there was no information about the EMS evacuation; and in 14 charts, there was no information about the treatment in the ED. More than 95% of the emergency vehicle charts were

Discussion

In a large cohort of adult patients transferred to the hospital by MICUs, 12.76% of the patients receiving medications in the emergency vehicle; and 36.1% of patients treated in the ED were subject to a medication error.

In the emergency vehicle as well as in the ED, a higher risk for error was found in patients treated with large number of medications. In the prehospital setting, long evacuation time was associated with higher risk for drug errors. In the ED, less errors were found in trauma

Conclusions

There are more medication errors in the ED than in emergency vehicles. Patients treated with a large number of medications are more prone to medication errors; trauma patients are less subject to medication errors.

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