Hospital Medication Errors: 1 In 5Sep 9, 2002 | Healthscout Hospitals and skilled nursing facilities in two states fumbled almost one of every five doses of medicine given to patients, says a new study.
Worse yet, nurses flubbed the doses even though they were being closely watched by the researchers.
"Assuming 10 doses per patient day, this would mean the typical patient was subject to about two errors every day," the authors write in their study, which appears in today's Archives of Internal Medicine.
Fortunately, not all the errors were potentially deadly. The authors estimate that only 7 percent of the incorrect or missing doses -- about one in 12 -- could have created significant "adverse" problems.
"Obviously, they're not killing people for the most part," says study co-author Kenneth N. Barker, director of the Center for Research on Pharmacy Operations and Designs at Auburn University in Auburn, Ala.
The study is only one in a series of recent reports that have described major problems regarding proper drug doses within the nation's hospitals and other medical facilities.
And it confirms there is a widespread problem that's "not going to be simple or inexpensive to deal with," Barker says.
In the new study, researchers looked at 36 randomly chosen hospitals -- both accredited and non-accredited -- and skilled nursing facilities in Georgia and Colorado. An additional 26 facilities declined to take part after being asked to participate.
Researchers watched the doses being given, and their correct amount was later confirmed by a pharmacist. A panel of doctors determined which mistakes were significant.
Of 3,216 doses given while nurses were observed, 605 -- 19 percent -- weren't what the doctor ordered. Of those, 43 percent were given at the wrong time, 30 percent weren't given at all, 17 percent were the wrong dose, and 4 percent were the wrong drug.
The error rates were not affected by the size of the medical facilities or whether they were accredited hospitals, non-accredited hospitals or skilled nursing facilities. However, errors were more likely in Colorado than in Georgia.
The American Hospital Association, which represents 5,000 medical facilities and networks, doesn't dispute the report, says Carmela Coyle, senior vice president for policy.
The report, like those released earlier, will help hospitals "improve our understanding not only of why errors occur, but also ways we can improve patient safety," she says. "This is not an area where you quibble with the numbers. We know that issues with medical errors are out there."
Hospitals can reduce mistakes by taking such steps as setting up special bins and wrapping for drugs that tend to be administered incorrectly, she says. Technology, including bar codes on medication bottles, can also help improve the ability of doctors and nurses to track drug treatment.
"When errors occur, it is usually not one mistake that's happening. It's a series or sequence of events," Coyle says. "The challenge is to build a system that can deal with the human factor."
Hospitals also need to emphasize safety instead of blaming those who make errors, she says.
And if all things work properly, she adds, "we should see an increase in the number of reported errors" as workers feel more comfortable in talking about them.