Retrospective analysis of mortalities associated with medication errors

Abstract

ResultsA total of 5366 medication error reports were identified during the time period. Of these, 3660 (68.2%) were classified, from a regulatory perspective (21 CFR 314.80), as serious (causing death, a threat to life, hospitalization, disability, congenital anomaly or requiring intervention to prevent permanent impairment or damage). Death resulted in 528 (9.8%) of these cases. We excluded 59 reports as duplicates or intentional overdoses. A total of 469 deaths were caused by medication errors. These are sorted by the year they were reported to FDA in Figure 1. Of these, 84 reports (18%) were directly reported to FDA by consumers and health care providers via the MedWatch program. Manufacturers reported 385 reports (82%) to FDA. The increase in reports during calendar year 1998 is probably reflective of FDA's decision to capture all medication error reports within one database (AERS) and no longer support a related database, the Drug Quality Reporting System. Figure.Reports of deaths per year received by FDA.Two hundred and seven deaths were assessed as related to an error, 219 as possibly related, and 43 as unrelated.

Potential Medication Dosing Errors in Outpatient Pediatrics

“…Particularly of concern to us was the high rate of potential overdoses of analgesics dispensed to children, because these drugs have a higher likelihood than other drugs of serious adverse and even fatal events associated with improper dosing. 3 In addition, the children most vulnerable to potentially serious adverse drug events, young and medically complex children, were also those most likely to be dispensed potential overdoses of medications. The IOM has identified computerization of medication prescribing as an important patient safety strategy.…”

“…1 Data from case reports, poison control centers, and the Food and Drug Administration's (FDA) MedWatch system [2][3][4] indicate that serious and even fatal medication errors occur in children each year. Although most medical care for children takes place in the outpatient setting, very little is known about the frequency and types of medication errors, their clinical importance, or effective strategies for error reduction in this setting.…”

Design for patient safety: A review of the effectiveness of design in the UK health service

“…The literature review also enabled specific problems to be identified and indicated how they might be solved. Best practices were highlighted , for instance, how using computerised prescriptions in GP surgeries have eliminated medication errors due to poor handwriting (Phillips et al 2001).…”

The “July Effect” Does Not Have Clinical Relevance in Liver Transplantation

“…During the month of July, medical errors are often attributed to the arrival of inexperienced residents, [1][2][3][4][5][6] fellows, and attending physicians. This potential seasonal influence on outcomes is termed the "July effect.…”