| Folli50 USA 1987 |
281 (hospital 1) and 198 (hospital 2) errant medication orders (4.9/1000 and 4.5/1000 medication orders, respectively)Total error rate: 15.2/1000 patient days (PICU 32.6/1000, NICU 8.2/1000, ward 19.4/1000) |
Overdose 264 (55.1)Underdose 129 (26.9)Wrong drug 27 (5.6)IV incompatibility 13 (2.7)Wrong route 9 (1.9)Drug interaction 9 (1.9)Drug allergy 2 (0.4)Other 26 (5.4) |
Frequency of errant orders declined as physicians' training status increased (p<0.001) |
All areas: no actual harm NICU:No actual harm Potentially lethal 0.04/100 patient days Serious 0.23/100 patient days Significant 0.55/100 patient days |
Paediatric pharmacists were able to detect errant medication orders and prevent medical errors |
| Vincer47 Canada 1989 |
313 Medication incidents on 23 307 patient days (13.4/1000 patient days, approximately 13/100 admissions) |
Human error 274 (87.5)Mechanical failures 8 (2.6)Other events 24 (7.7)Unknown 7 (2.2) |
Administration 84 (27):Neglecting to give a drug on scheduled time 52 (17)Failure to follow procedures 56 (18):Intravenous infusion not properly regulated 32 (10)Physician's orders incorrect 51 (16)Faulty drug preparation 26 (8)Transcription of physician's order 26 (8)Interstitial intravenous line 18 (6)Other 52 (17)Relative risk of medication incidents increased with increasing level of care (p<0.01)Three serious errors were caused by verbal orders that differed from the subsequently written order |
Errors in physician's orders resulted in more serious incidents (incidents with (potential for) patient morbidity), 20% compared with 6% of all other causes (p<0.001) |
Not described |
| Raju39 USA 1989 |
315 Medication related errors among 2147 admissions (14.7/100 admissions, 8.8/1000 patient days) |
Wrong time 68 (21.6)Wrong rate 43 (13.7)Wrong dose 43 (13.7)Unauthorised drug 42 (13.3)Wrong technique 41 (13.0)Omission 39 (12.4)Wrong preparation 26 (8.3)Wrong route 13 (4.1) |
Improper placement of the decimal point was the commonest error in calculation |
Substantial injury (long term injury, toxic effects or death) 1 (0.3)Mild injury (no substantial treatment or intervention) 32 (10.2)No apparent injury 250 (79.4)Potentially serious (drug serum level in toxic range, or insufficient dose of a life‐saving drug) 33 (10.5) |
Not described |
| Frey23 Switzerland 2000 |
211 (45/100 neonatal admissions, 40/100 paediatric admissions) |
Management/environment 62 (29)Drugs 62 (29):Wrong dose 37 Wrong drug 11 Procedures 37 (18)Respiration 29 (14)Equipment dysfunction 15 (7)Nosocomial infections 6 (3) |
Human error (63)Communication (14)Organisational problems (10)Equipment dysfunction (7)Milieu (3)No contributing factor identified (3) |
Major: death (0), need for therapeutic intervention specific to the ICU (30)Moderate (requiring routine treatment available outside ICU) (25)Minor (no intervention required) (45)Most severe: incidents relating to respiration |
Not described |
| Ross51 UK 2000 |
Total hospital: 195 medication errors (0.15/100 admissions, 0.51/1000 patient days)NICU: 33 medication errors (0.83/100 admissions, 0.97/1000 patient days)PICU: 20 medication errors (0.61/100 admissions, 1.6/1000 patient days) |
Parenteral medicines 109 (56):Antibiotics 48 Oral medicines 66 (34)Other route 20 (10)Incorrect IV infusion rate 32 (15.8)Incorrect dose given 30 (14.8)Extra dose given 28 (13.8)Dose omitted 25 (12.3)Incorrect drug given 25 (12.3)Incorrect IV concentration 21 (10.3)Labelling error 20 (9.9)Incorrect route 9 (4.4)Incorrect patient 8 (3.9)Incorrect strength 1 (0.5)Other 4 (2) |
Double check did not occur 58 (30)Unknown whether checking occurred 7 (3)Intravenous pump errors 23: many different types of syringe pump and volumetric pump in use Tenfold dosing errors 15 (8):5 Miscalculations of dose despite clear prescribing 4 Incorrect or unclear prescribing 1 Inaccurate verbal communication |
Long term morbidity or mortality 0 Serious (potential severe harm) 2 (1)Medium severity (clinical symptoms aggravated by error) 3 (2)Minor (no actual harm resulted) (96) Errors requiring active patient intervention 18 (9.2) |
Errors involving morphine sulphate occurred when 10 mg, 15 mg and 30 mg ampoules were available. In one case ampoules had been confused |
| Kaushal15 USA 2001 |
616 Medication errors (5.7/100 orders, 55/100 admissions, 157/1000 patient days)115 Potential ADEs 26 ADEs Neonates in the NICU:Medication errors 91/100 admissions Potential ADEs 46/100 admissions Neonates in other wards:Medication errors 50/100 admissions Potential ADEs 9/100 admissions |
Dose 175 (28)Frequency 58 (9.4)Route 109 (18)Administration 85 (14)Wrong drug 8 (1.3)Wrong patient 1 (0.16)Known allergy 8 (1.3)Illegible order 14 (2.3)Missing or wrong weight 74 (12)No or wrong date 74 (12)Other 61 (9.9) |
Prescription 454 (74)Transcription 62 (10)Administration 78 (13)Patient monitoring 4 (0.6)Missing 12 (1.9) |
ADEs:Fatal or life‐threatening 2 (7.7)Serious 9 (34.6)Significant 15 (57.7)Potential ADEs:Fatal or life threatening 18 (15.7)Serious 52 (45.2)Significant 45 (39.1) |
Preventable ADEs: 5 (0.52/100 admissions)Non‐preventable ADEs: 21 (1.9/100 admissions) |
| Frey24 Switzerland 2002 |
284 Drug related incidents (including IV fluids and enteral and parenteral nutrition) |
Catecholamines 31 (11)Anticoagulants 30 (11)Electrolytes 30 (11)Crystalloids 22 (8)Opiates 24 (9)Antibiotics 17 (6)Other 95 (34) |
Prescription 102 (37)Preparation 162 (59)Administration 200 (73) |
Major: death (0), need for therapeutic intervention specific to the ICU (5)Moderate (requiring routine treatment available outside ICU) (19)Minor (no intervention required) (76)Potentially life‐threatening 24 (8)Most severe: sedative drugs, crystalloids and enteral nutrition |
75 (27) Incidents were caught before administration |
| Simpson41 UK 2004 |
105 Medication errors (14.7/1000 patient days):24.1/1000 Patient days before intervention 5.1/1000 Patient days after intervention (pharmacist‐led education programme)12.2/1000 Patient days after start of new junior medical staff |
Parenteral medicines 63 (60):Antibiotics 40 Morphine 6 Oral medicines 41 (39)Topical medicines 1 (1) |
Prescription 75 (71):37 Incorrect doses 19 Incorrect dose intervals 14 Incomplete prescriptions 5 Incorrect units Administration 30 (29):16 Poor documentation or communication |
Most severe: two 10‐fold dose miscalculations Serious (actual harm or very high risk of harm to the infant) 4 (4)Potentially serious (potential harm to the infant) 45 (43)Minor 56 (53) |
A change over of junior medical staff was associated with an increase in medication errors |
| Suresh43 USA 2004 |
1230 Reports: 522 from phase 1 (free text reports) and 708 from phase 2 (structured reports) |
Errors of diagnosis 137 (11.2)Errors of treatment 949 (77.2)Errors of prevention 0 Other errors 144 (11.7)Of all reported events, 581 (47%) were related to medication, nutritional agents or blood products:Administration (31)Dispensing (25)Ordering (16)Transcribing (12)Monitoring (1.4)Wrong drug (8.4)Uncertain (6) |
In 584 (82.5) phase 2 reports at least one contributing factor was reported. In 52 (8.9) reports, 5– 8 factors were selected for each report Most frequent contributing factors in these 584 reports:Failure to follow policy/protocol 273 (47)Inattention 157 (27)Communication problem 131 (22)Charting or documentation error 78 (13)Distraction 69 (12)Inexperience 59 (10)Labelling error 56 (10)Poor teamwork 50 (9) |
Outcome reported in 673 phase 2 reports:Actual harm 181 (27):Death 1 (0.2)Serious (threat to life, impaired outcome) 13 (1.9)Minor (increased monitoring, intervention) 167 (25)Potential harm, reached patient, no harm (34)Potential harm, did not reach patient (25)No potential for harm (14) |
Not described |
| Kanter14 USA 2004 |
824 (1.2/100) Premature neonates experienced a medical error |
Procedural complications (60), including mechanical complications of device implants and grafts Medical care complications (25) |
Significant inverse linear association between birth weight and medical error rates (birth weight 2000–2499 g, 0.6%, versus birth weight 500–749 g, 5.2%, p<0.001)More errors in urban teaching centres than in rural or urban non‐teaching centres (OR = 1.69; CI 1.18 to 2.43) |
Not described |
Not described |
