Retrospective Analysis of Mortalities Associated With Medication Errors

Jerry Phillips, Sammie Beam, Allen Brinker, Carol Holquist, Peter Honig, Laureen Y. Lee, and Carol Pamer

Am J Health Syst Pharm. 2001;58(19)

Conclusion

A review of case reports of medication errors from 1993 to 1998 yielded information on the most frequent causes of and contributing factors involved in fatal medication errors.

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Acknowledgments

The assistance of Melissa Bates, Paul Reinstein, Maureen Majors, Mary Willy, Ph.D., and Anne Trontell, M.D., is acknowledged.

Cite this: Retrospective Analysis of Mortalities Associated With Medication Errors - Medscape - Oct 01, 2001.

Figure 1. Distribution of Deaths by Age
Age (yr)	No. (%) Deaths ^[a]
0-9	49 (10.4)
10-19	20 (4.3)
20-29	23 (4.9)
30-39	28 (6.0)
40-49	32 (6.8)
50-59	30 (6.4)
60-69	47 (10.0)
70-79	71 (15.1)
80-89	43 (9.2)
> 90	11 (2.3)
Unknown	115 (24.5)

^an = 469.

Table 2. Distribution of Deaths Associated with Concurrent Drug Usage
No. Drugs Taken	No. (%) Deaths ^[a]
1	246 (52.5)
2	82 (17.5)
3	43 (9.2)
4	28 (6.0)
5	48 (10.2)
6	22 (4.7)

^an = 469.

Table 3. Distribution of Deaths by Pharmacologic Category
Pharmacologic Class	No. (%) Deaths	Representative Example(s) (No. Cases)
Antihistamine drugs	4 (0.8)	Seldane (3)
Anti-infective agents	35 (7.5)	Amphotericin (5); Diflucan (4)
Antineoplastic agents	72 (15.4)	Cisplatin (12); Vincristine (14)
Autonomic drugs	26 (5.5)	Epinephrine (4); Albuterol (3)
Blood derivatives	7 (1.5)	Albumin (3)
Blood formation and coagulation agents	25 (5.3)	Coumadin (10); Heparin (7)
Cardiovascular drugs	59 (12.6)	Brevibloc (10); Lidocaine (7)
Central nervous system agents	126 (26.9)	Opiates (31); acetaminophen (8)
Diagnostic agents	8 (1.7)	Renografin-60 (1)
Electrolytic, caloric, and water balance	31 (6.6)	Potassium chloride (14)
Antitussives, expectorants	3 (0.6)	Rondec-DM (1); Tessalon (1)
Eyes, ears, nose, and throat	1 (0.2)	Epinephrine mist (1)
Gastrointestinal agents	11 (2.3)	Propulsid (5); Fleet enema (1)
Hormones and synthetic substitutes	31 (6.6)	Insulin (10), Depo-Medrol (3)
Local anesthetics	1 (0.2)	Marcaine (1)
Oxytocics	2 (0.4)	Pitocin (1)
Unclassified or other therapeutic agents	27 (5.8)	Exosurf (3)
Total	469 (100)

Table 4. Types of Errors
Error	No. (%)
Improper dose
Overdose	216 (36.4)
Underdosage	8 (1.3)
Extra dose	6 (1.0)
Not classified	13 (2.2)
Wrong drug	96 (16.2)
Wrong route of administration
Intrathecal instead of i.v.	14 (2.4)
I.V. instead of oral	8 (1.3)
I.V. instead of i.m.	4 (0.7)
I.M. instead of i.v.	1 (0.2)
Other	30 (5.1)
Wrong patient	16 (2.7)
Wrong rate	33 (5.6)
Wrong strength/concentration	34 (5.7)
Wrong dosage form	3 (0.5)
Wrong technique	11 (1.9)
Wrong time	3 (0.5)
Monitoring error	27 (4.5)
Deteriorated drug error	10 (1.7)
Wrong duration	15 (2.5)
Dose omission	3 (0.5)
Noncompliance	9 (1.5)
Other	34 (5.7)
Total	594 (100)

Table 5. Causes of Errors [a]
Cause	No. (%)	Representative Example(s) (No. Occurrences)
Human factors (n = 380)
Performance deficit	174 (29.8)	Administering an i.v. Injection when intended to be given i.m.
Knowledge deficit	83 (14.2)	Reasonable practice standards would have prevented an error
Miscalculation of dosage	76 (13.0)
Drug preparation	34 (5.8)	Using the wrong amount of diluent (5), adding the wrong drug (9), adding the wrong amount of active ingredient (4)
Other	13 (2.2)	Incorrect selection of drug from a computer (2), transcription errors (7)
Communication (n = 92)
Misinterpretation of order	43 (7.4)
Oral miscommunication	10 (1.7)
Written miscommunication	39 (6.7)	Misreading order (17), making 10-fold errors because of decimal points (12)
Name confusion (n = 52)
Proprietary name confusion	28 (4.8)	Sound alike (11), look alike(9)
Established name confusion	24 (4.1)	Sound alike (8), look alike (9)
Labeling (n = 32)
Immediate container label of the manufacturer	21 (3.6)	Appears misleading (7), too similar within the same company's line (6)
Label of dispensed product (practitioner)	5 (0.9)	Wrong directions (2), wrong drug name (1)
Manufacturer's carton	5 (0.9)	Looks similar to another manufacturer's (2)
Printed reference material	1 (0.2)	Inaccurate printed information (1)
Packaging and design (n = 27)
Device problems	16 (2.7)	Malfunction (4), infusion problems (6), wrong device selected (2)
Inappropriate packaging or design	8 (1.4)	Topical product packaged in sterile i.v. multiple-dose vial
Tablet or capsule confusion	3 (0.5)

^an = 583.

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