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<title>Research Activities, October 1995: Feature Story: System and equipment changes could reduce hospital medication errors</title>
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<p><strong>You Are Here:</strong> <span class="crumb_link"><a href="/" class="crumb_link">AHRQ Archive Home</a> &gt; <a href="/research/resarch.htm" class="crumb_link"><em>Research Activities</em> Archive</a> &gt; <a href="." class="crumb_link">October 1995</a>
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<td><h1><a name="h1" id="h1"></a> Feature Story </h1>
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<p>This information is for reference purposes only. It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work. Persons with disabilities having difficulty accessing this information should contact us at: <a href="https://info.ahrq.gov/">https://info.ahrq.gov</a>. Let us know the nature of the problem, the Web address of what you want, and your contact information. </p>
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<h2>System and equipment changes could reduce hospital
medication errors</h2>
<p>Adverse drug events (ADEs) cause nearly one out of five injuries
or deaths to hospital patients each year. Although some ADEs are
not preventable, those due to physician, nurse, or pharmacy error
can be prevented. Overhauling the system rather than punishing
personnel is the way to reduce these errors, according to two
studies that were supported in part by the Agency for Health Care
Policy and Research (HS07107). Findings from these studies
indicate that many ADEs could be avoided if hospitals upgraded
their computer systems, standardized drug ordering and
administration procedures, and improved communication between
departments.</p><p>
Led by Lucian L. Leape, M.D., of the Harvard School of Public
Health, researchers studied all adults admitted to 11 nursing
units at two large Boston hospitals over a 6-month period from
February through July 1993. Nurses and pharmacists reported
incidents to nurse investigators, who also reviewed patient
charts to detect actual or potential drug-related incidents.
During this time, the researchers found 247 ADEs, of which 70 (28
percent) were preventable and 194 potential ADEs of which 83 (43
percent) were intercepted before the drug was given. The adjusted
rates per 100 nonobstetric admissions were 6.5 for ADEs and 5.5
for potential ADEs. Errors resulting in preventable ADEs occurred
most often at the stages of drug ordering (56 percent) and
administration (34 percent). Errors in transcribing the doctor's
order (6 percent) and pharmacy dispensing (4 percent) were less
common.</p>
<p>As part of the study, the researchers performed a systems
analysis to identify and evaluate the systems failures underlying
the errors that caused the ADEs and potential ADEs. Dosing errors
were by far the most common type of error, accounting for 28
percent of all errors. Most of the wrong-dose errors (50 of 95)
occurred in the physician ordering stage and were primarily due
to the physician's lack of knowledge about the drug or about the
patient for whom it was prescribed.</p><p>
The most common systems failure was in the dissemination of drug
knowledge, particularly to physicians, accounting for 29 percent
of errors. Inadequate availability of patient information, such
as the results of laboratory tests, was associated with 18
percent of errors. Failures in seven hospital systems accounted
for 78 percent of errors: drug knowledge dissemination, dose and
identity checking, patient information availability, order
transcription, allergy-alert system, medication order tracking,
and interservice communication.</p>
<p>More details are in "Incidence of adverse drug events and
potential adverse drug events," by David W. Bates, M.D., M.Sc.,
David J. Cullen, M.D., Nan Laird, Ph.D., and others, and in
"Systems analysis of adverse drug events," by Dr. Leape, David W.
Bates, M.D., M.Sc., David J. Cullen, M.D., and others, as well as
a related editorial, "Above all 'do no harm:' How shall we avoid
errors in medicine?" by Katherine L. Kahn, M.D., all of which
appear in the July 5, 1995, issue of the <em>Journal of the
American Medical Association</em> 274(1), pp. 29-34, 35-43, and
75-76.</p>
<p class="size2"><a href=".">Return to Contents</a><br />
<a href="dept1.htm">Proceed to Next Section</a></p>
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<p> The information on this page is archived and provided for reference purposes only.</p></div>
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