November 2003

Research reveals drug errors

Researchers recently reviewed the case histories of 24,538 patients who were admitted to cardiology wards and found an astonishing 4,768 pharmacist interventions that were related to medication errors ‑‑ a total of nearly one in every four patients.

The most common errors included wrong drug (36%) or wrong dose (35.3%). Cardiovascular medications were involved in 41.2% of the errors recorded ‑‑ a finding that is particularly alarming since most cardiovascular medications are extremely powerful and associated with severe adverse reactions.

"Three notable medication error trends were identified in our study, including: 1) a high number of errors attributed to lack of knowledge of the patient's drug therapy before admission, 2) an increase in errors during periods of house staff transition, and 3) a gradual increase in the number of medication errors during the study period," wrote the authors. They did not provide information on drug errors that would not caught by the pharmacist on duty at the hospital.

SOURCE: "Medication Errors in Hospitalized Cardiovascular Patients," by Nancy M. Allen LaPointe, Pharm.D; James G. Jollis, M.D. Archives of Internal Medicine. 2003;163:1461‑1466 (June 23,2003).