Medication Omission Common Cause of Fatal Med Errors

Troy Brown, RN

December 12, 2018

Fatal medication errors are most common with anticoagulants and antibiotics, a new study shows. The most common types of medication administration errors (MAEs) were medication omissions, followed by administration of a wrong dose or wrong strength of medication. Half of the reported incidents involved a patient older than 75 years.

"Our findings show that more attention should be paid to the safe administration of medication especially when it comes to older people. It is important to make sure that the patient gets the right dose of medication at the right time and in the right way," lead author Marja Härkänen, RN, PhD, postdoctoral researcher, Academy of Finland, University of Eastern Finland, said in a news release.

Härkänen's and colleagues' findings were published online November 22 in Research in Social and Administrative Pharmacy.

The researchers analyzed 229 fatal MAEs reported to the National Reporting and Learning System for England and Wales between 2007 and 2016. A total of 517,384 medication errors were reported.

Two thirds (66.4%; n = 152) of fatal MAEs occurred on hospital wards, and 41.5% (n = 95) of patients were older than 75 years.

The most common drug groups involved in fatal MAEs were cardiovascular drugs (20.1%; n = 46), drugs that affect the central nervous system (10.0%; n = 23), and antibacterials (n = 20). The most frequently involved drug types were injectable anticoagulants, antibiotics, and analgesics.

For anticoagulants, the difference between an effective dose and a toxic dose is small, making errors with these drugs more likely to cause death than errors involving some other types of drugs.

Most MAEs related to antibacterial drugs were omissions, those involving adverse drug reactions, and those that occurred in patients with a documented allergy. Drugs that treat infection were the most common drugs involved in MAEs in children younger than 12 years.

The most common types of errors involving medications that affect the central nervous system, including opioids, were those involving "wrong or unclear dose or strength, wrong drug, or wrong quantity," the authors write.

Overall, almost one third of MAEs were omissions of a medication or ingredient (31.4%; n = 72), followed by administration of a wrong dose or at the wrong strength (10.5%; n = 24).

Omission of anticoagulants, insulins, and cytotoxic agents "can cause significant or catastrophic long-term patient impact," the authors write. Possible reasons for medication omissions include staff shortages and delays in medication administration, inability of patients to take their medication, and medication unavailability.

The researchers encourage the implementation of "more active solutions" through the development of technology, improved work processes and information flow, verification systems, and drug availability.

They say it is difficult to recommend specific interventions, however, noting that a previous systematic review and meta-analysis found no clear effect of interventions, including nurse training and education, automated delivery systems, and barcode-assisted medication administration systems.

"Although all errors do not cause harm to the patient, it is important to work to prevent especially those that do. This requires sufficient human resources and competent staff, as well as technological and digital solutions that promote competence development among staff, and that ensure medication safety," Katri Vehviläinen-Julkunen, PhD, RN, director of the doctoral program in health sciences at the University of Eastern Finland, said in the news release.

A strength of the study is that it was large enough to detect rare MAEs that resulted in death. A limitation of the study is that MAEs may have been underreported, the authors write.

"While incident report data are subject to under-reporting, under-reporting may be less likely for errors that result in death, and so this study also represents a useful approach to learning from reported medication incidents. It also highlights the importance of preventing the omission of doses, as these were commonly implicated in our data," coauthor Bryony Dean Franklin, PhD, FRPharmS, FFRPS, from University College London and the National Institute for Health Research Imperial Patient Safety Translational Research Center, noted in the news release.

One author reports supervising a PhD student partly funded by Cerner, a supplier of hospital electronic health record systems, and has received funding from Pfizer for delivering teaching at a symposium on medication safety unrelated to this study.

Res Soc Adm Pharm. Published online November 22, 2018. Full text

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