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Studies done on administration error
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#
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Setting
|
Methodology
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Study duration
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Population
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Sample
|
Results
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Total number of erroneous administrations
|
Reference
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| 1 |
Malaysia (Paediatric ward of a teaching hospital) |
Direct observational study |
10 days over 10 weeks |
50 patients age less than 16 years old; admitted to the pediatric ward |
857 administrations |
Incorrect dose form: 2% Incorrect time: 30% Incorrect technique: 9% Unauthorized drug: 7% Omission error: 17% due to out of stock Incorrect dose: 12% Incorrect preparation: 27% |
11.7% (100 of the 857 administrations observed) |
[12] |
| 2 |
Malaysia (tertiary care hospital) |
Prospective observational study |
3 months |
Patients hospitalized in all 24 wards of the hospital |
349 IV drugs which were prepared and administered by the staff nurses to the patients. |
Wrong time: 42.1% Wrong technique: 19.5% Wrong administration rate: 85.1% |
88.6% (302 of the 349 administrations observed) |
[13] |
| 3 |
Malaysia (haematology ward of a teaching hospital in Malaysia) |
Prospective study that involved direct, undisguised observations of drug administrations |
15 days |
Patients hospitalized in the heamatology ward of the hospital |
1118 total opportunities for error |
Incorrect drug: 0.7% Extra dose: 2.2% Administration of expired medications: 2.2% Incorrect rate: 5.9% Omission: 10.4% Incorrect dose: 10.4% Incorrect drug preparation: 10.4% Unauthorized drug: 14.1% Incorrect technique: 16.3% Incorrect time: 25.2% |
11.4% (127 of the 1118 administrations observed) |
[14] |
| 4 |
Singapore (public sector and private practice anaesthesiologists in Singapore) |
Survey |
1 month |
174 anaesthetists, trainees and specialists in public institutions or in private practice |
350 survey forms |
Misidentification of the ampoule: 53% Misidentification of syringes: 45% |
45.4% (159 of the 350 errors/near misses reported) |
[15] |
| 5 |
Singapore (two acute care hospitals) |
Descriptive, prospective design |
12 weeks |
140 registered full time nurses |
21043 opportunity for error (doses given or doses orders but omitted) An opportunity for error included any dose given plus doses ordered to be given but omitted |
Of the 140 participants, only 10% (14/140) were not observed to encounter any distractions during medication administration, while 90% (126/140) were distracted during the observations |
45.4% (5024 out of the 21043 opportunities for error) |
[16] |
| 6 |
Vietnam (2 public hospitals) |
Direct observational study |
7 days |
Diabetic patients in ward |
229 insulin doses (204 subcutaneous and 25 infusions) |
Delayed dose: 10.4% Early dose: 7.4% Administration technique error: 3.1% Omission: 2.6% |
28.8% (66 of the 229 insulin doses) |
[17] |
| 7 |
Vietnam (6 wards in 2 urban public hospitals) |
Prospective observational |
3 months |
|
5271 doses administered |
Wrong administration technique: 23.5% Wrong preparation technique: 15.7% Omission: 2.3% Wrong dose: 1.8% |
39.1% |
[18] |
| 8 |
Indonesia-Bali (Geriatric ward in a public teaching hospital) |
Prospective study |
20 weeks |
Geriatrics (>60 years old) patients in ward |
7662 doses |
Administration errors: 59% |
20.4% (1,563 medication errors of 7,662 drug doses reviewed) |
[19] |
| 9 |
Philippines (University-based tertiary hospital) |
Questionnaire |
|
Junior and senior nursing students who routinely administer medications within a university-based tertiary hospital |
329 questionnaires |
Missed dose: 41.94% Wrong time: 40.32% |
18.8% (63 out of the 329 respondents) |
[20] |
| 10 |
Thailand (7 university hospitals, 5 tertiary care hospitals, 4 secondary care hospitals, 4 primary care hospitals) |
Prospective data collection |
18 months |
Patients anaesthetized in 20 participating hospitals in Thailand |
202699 anaesthesia cases |
Wrong drug: 48.8% Incorrect dose: 29.3% |
0.02% (41 of the 202699 cases) |
[21] |
| 11 |
Thailand (Queen Sirikit National Institute of Child Health) |
Retrospective study (screening medication errors documents and reports) |
15 months |
Medical records from September 2001 to November 2002 |
Medication errors in ward documented in standard reporting forms based on the 32106 admissions |
Administration error: 15.22% Wrong time: 2.17% Omission 1.24% Wrong strength: 1.86% Unauthorized drug: 0% Wrong patient: 2.48% Extra dose: 3.73% Wrong dose form: 3.73% |
1% (322 of the 32105 admissions medical report) |
[22] |
|
Studies done on dispensing error
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| 1 |
Indonesia-Bali (Geriatric ward in a public teaching hospital) |
Prospective study |
20 weeks |
Geriatrics (>60 years old) in ward |
7662 doses |
Dispensing errors: 14% Omission: 39.6% |
20.4% (1,563 medication errors of 7,662 drug doses reviewed) |
[19] |
| 2 |
Thailand (Queen Sirikit National Institute of child health) |
Retrospective study (screening ME documents and reports) |
15 months |
Medical records from September 2001 to November 2002 |
32105 |
Dispensing: 34.78% |
1% (322 errors of the 32105 admissions) |
[22] |
|
Studies done on prescribing error
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| 1 |
Malaysia (outpatient pharmacy in a teaching hospital in Kelantan) |
Retrospective study. (screening prescriptions) |
1 month |
Geriatrics at the outpatient pharmacy |
1601 prescriptions for geriatrics |
Pharmaceutical (stability, ingredient, technique): 0.99% Clinical errors (dose,frequency, interaction,allergy): 8.68% |
25.15% (403 of the 1602 prescriptions) |
[23] |
| 2 |
Indonesia (Geriatric ward in a public teaching hospital in Bali) |
Prospective study |
20 weeks |
Inpatient geriatrics (>60 years old) |
7662 doses |
Prescribing errors: 7% |
20.4% (1,563 of the 7,662 drug doses reviewed) |
[19] |
| 3 |
Singapore (Paediatric unit in a university teaching hospital) |
Prospective cohort study |
4 months |
Children (<16 years of age) at the outpatient clinic, emergency department and at discharge from the inpatient service |
4274 paediatric prescriptions |
Under-dose: 64% No frequency specified: 21%Overdose: 8% |
19.5% (833 of the 4274 prescription screened) |
[24] |
| 4 |
Thailand (Queen Sirikit National Institute of child health) |
Retrospective study (screening ME docs and reports) |
15 months |
Medical records from September 2001 to November 2002 |
32105 |
Prescription error: 35.4% Wrong dose: 25.78% Wrong choice: 3.73% Known allergy: 0.62% |
1% (322/32,105 admissions) |
[22] |
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Studies done on transcribing error
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| 1 |
Malaysia (outpatient pharmacy in a teaching hospital (HUSM) in Kelantan) |
Retrospective study. (screening prescriptions) |
1 month |
Geriatrics at the outpatient pharmacy |
1601 prescriptions for geriatrics |
Miswriting patient particulars: 70.22% |
25.15% (403/1602 prescriptions) |
[23] |
| 2 |
Indonesia (Geriatric ward in a public teaching hospital in Bali) |
Prospective study |
20 weeks |
|
7662 doses |
Transcription errors: 15% |
20.4% (1,563/ 7,662 drug doses reviewed) |
[19] |
|
Studies done on preparation error
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| 1 |
Malaysia (tertiary care hospital) |
Prospective observational study |
3 months |
Patients hospitalized in all 24 wards of the hospital |
349 IV drugs prepared and administered by nurses |
Preparation errors: 32.8% Wrong amount of diluents: 54.5% |
88.6% (302 of the 349 administrations observed) |
[13] |
| 2 |
Vietnam (Two large public hospitals in Vietnam) |
Direct observational study |
7 days |
Diabetic patients admitted in wards |
229 insulin doses (204 subcutaneous and 25 infusions) |
Incorrect preparation technique: 22.7% |
28.8% (66 of the 229 insulin doses) |
[17] |
| 3 |
Vietnam (two urban public hospitals in Vietnam) |
Prospective observational |
3 months |
6 wards |
5271 oral and IV doses administered |
Wrong preparation technique: 15.7% |
39.1% (2060 of the 5271 administration) |
[18] |
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Studies done on reconciliation error
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| 1 |
Singapore (Tan Tock Seng Hospital) |
Descriptive |
NA |
5100 patients admitted |
Reconciliation forms created by pharmacy staff for each patient admitted |
Transcription error: 36.5% Prescribers missing out medications from their list: 61.65% Wrong or incomplete regimen: 25.4% |
18.13% (925 of the 5100 patients admitted) |
[25] |
