Hiroto Ito1, Syun Yamazumi. 1. Healthcare Evaluation Section, Department of Management Science, National Institute of Public Health, Wako, Saitama, Japan. ito@niph.go.jp
Abstract
OBJECTIVE: This multi-center study identified the most frequent types of medication errors in long-term psychiatric care hospitals. SETTING: Japan. DESIGN AND STUDY PARTICIPANTS: We asked 132 units in 44 Japanese psychiatric hospitals to introduce an in-patient incident reporting system on potential adverse drug events (PADEs) for the period 1 October to 30 November 2000. We analyzed types of PADE, outcomes, and characteristics of patients, staff, and units. RESULTS: We received 221 PADE incident reports from 85 units of 44 hospitals. One-quarter (24.9%) of the incidents were intercepted before reaching patients. The frequency of monitoring of the patients by clinical staff in response to medication errors increased by 8.1%. Wrong drug administration, i.e. giving a drug to a patient that was not the drug prescribed for that patient, was the most common type of incident (35.7%). Logistic regression analysis revealed that wrong drug administration occurred more frequently on units with either fewer registered nurses, or two or more patients with the same (or similar) name staying on the same unit. Incident reporters evaluated wrong drug administration as being potentially more serious than the other types of medication error. Wrong drug administration was seen more frequently in units with no patient name printed on medication drug pouches. CONCLUSIONS: Wrong drug administration was the most common type of PADE, and may result in more serious consequences than others. Even a simple organizational quality improvement effort, in which printed patients' names are placed on the drug pouch (not only with each prescription but with each drug administration), could reduce risk to patients from adverse outcomes due to medication errors.
OBJECTIVE: This multi-center study identified the most frequent types of medication errors in long-term psychiatric care hospitals. SETTING: Japan. DESIGN AND STUDY PARTICIPANTS: We asked 132 units in 44 Japanese psychiatric hospitals to introduce an in-patient incident reporting system on potential adverse drug events (PADEs) for the period 1 October to 30 November 2000. We analyzed types of PADE, outcomes, and characteristics of patients, staff, and units. RESULTS: We received 221 PADE incident reports from 85 units of 44 hospitals. One-quarter (24.9%) of the incidents were intercepted before reaching patients. The frequency of monitoring of the patients by clinical staff in response to medication errors increased by 8.1%. Wrong drug administration, i.e. giving a drug to a patient that was not the drug prescribed for that patient, was the most common type of incident (35.7%). Logistic regression analysis revealed that wrong drug administration occurred more frequently on units with either fewer registered nurses, or two or more patients with the same (or similar) name staying on the same unit. Incident reporters evaluated wrong drug administration as being potentially more serious than the other types of medication error. Wrong drug administration was seen more frequently in units with no patient name printed on medication drug pouches. CONCLUSIONS: Wrong drug administration was the most common type of PADE, and may result in more serious consequences than others. Even a simple organizational quality improvement effort, in which printed patients' names are placed on the drug pouch (not only with each prescription but with each drug administration), could reduce risk to patients from adverse outcomes due to medication errors.