Table 6.
Non-missed-dose Medication Errors, By Type and Period
| Baseline (n = 10,070) | Period 1 (n = 15,025) | Period 2 (n = 13,139) | Period 3 (n = 14,352) | P* Value | |
|---|---|---|---|---|---|
| Dose errors | 81 (47.5) | 90† (34.3) | 114† (63.9) | 40† (21.3) | 0.03 |
| Frequency errors | 43 (25.2) | 4 (1.5) | 2 (1.1) | 4 (2.1) | 0.0001 |
| Route errors | 25 (14.7) | 5 (1.9) | 6 (3.3) | 4 (2.1) | 0.0001 |
| Substitution errors | 12 (7.0) | 3 (1.1) | 3 (1.7) | 0 (0) | 0.0001 |
| Documented allergy | 10 (5.9) | 1 (0.4) | 1 (0.6) | 0 (0) | 0.0001 |
| Inappropriate drug | 7 (4.1) | 3 (1.1) | 1 (0.6) | 0 (0) | 0.002 |
| Avoidable delay | 7 (4.1) | 0 (0) | 0 (0) | 0 (0) | 0.003 |
| Drug-drug interaction | 2 (1.2) | 0 (0) | 1 (0.6) | 0 (0) | 0.19 |
| Inadequate follow-up | 1 (0.6) | 0 (0) | 0 (0) | 0 (0) | 0.17 |
| Other | 54 (31.7) |
28 (10.7) |
4 (2.2) |
2 (1.1) |
0.0001 |
| Total |
242 (142.0) |
134 (51.2) |
132 (74.0) |
50 (26.6) |
0.0001 |
| Note: The number of occurrences of each error is shown, followed by the rate per 1,000 patient-days in parentheses. | |||||
*
The P value was determined by the chi-squared test for trend across the four periods.
†
Of these errors, 77 of 90 (86 percent) in period 1 and 101 of 114 (89 percent) in period 2 were potassium chloride errors, whereas none of the 40 dose errors in period 3 was a potassium chloride error.