Experience with a national medication error reporting program.

Actual or potential medication errors reported to a national medication error database from August 1991 through April 1993 are summarized. The United States Pharmacopeial Convention (USP) and the Institute for Safe Medication Practices (ISMP) collect medication error reports and study them in an effort to provide feedback to practitioners, the FDA, and product manufacturers. Reports are voluntary and are most often received by telephone or submission of a standard form. Five hundred sixty-eight such reports were received by the USP between August 1991 and April 1993; the majority of these were from pharmacists. Medication errors were classified as potential, actual-intercepted, or actual-transpired; 406 actual errors occurred in the prescribing, transcribing, communication, dispensing, or administration of medications, and 162 incidents involved potential errors in these areas. Nurses, pharmacists, and physicians were implicated in the greatest number of triggering incidents. The drugs most commonly involved in errors were heparin, lidocaine, epinephrine, and potassium chloride; lidocaine was implicated in the largest number of fatalities. Product problems (e.g., similar packaging, incomplete labeling) played the largest role overall, whereas cognitive error was the most important factor in fatalities. A national medication error reporting program can provide valuable feedback to practitioners and manufacturers.