Medication Errors in Emergency Department Settings – 5 Year Review

The United States Pharmacopeia, Rockville, Maryland
Center for the Advancement of Patient Safety
John P. Santell, M.S., R. Ph.
Rodney W. Hicks, M.P.A., M.S.N., R.N.
Diane D. Cousins, R, Ph.

Presented June, 2004
American Society of Health-Systems Pharmacists
Summer Meeting (Las Vegas, Nevada)

Background

Pharmacists typically have not played a prominent role in Emergency Departments (EDs). The complexity and fast-paced nature of care provided in the ED increase the chance for medication errors to occur in this setting. Studies examining medication errors from a national, aggregate perspective have not been previously conducted.

Methods

Medication errors that originated in the ED and were submitted to MEDMARX® over a 5-year period were examined. Each of the error reports were examined for the severity of the error (an outcome measure using the National Coordinator Council for Medication Error Reporting and Prevention's Index for Classifying Medication Errors), the phase of the medication use process where the error was reported to have originated, the type of error, the cause of the error, the product(s) involved in the error, and the level of staff identified has having made the medication error.

Results

A total of 10,998 medication error reports were reviewed from 488 unique facilities. Medication errors that resulted in harm occurred in 4.8% of the cases reviewed (and included 5 fatalities), which is more than double the overall pattern seen in MEDMARX. Errors involving children accounted for 6.4% of the cases. Errors were reported in each of the phases of the medication use process with Administering phase representing the largest percentage overall and when harm was reported. Wrong administration technique was disproportionately associated with harmful errors (13.5%). High alert medications, including heparin, insulin, and morphine were common as well as antimicrobial agents.

Recommendations

Expanding the utilization of pharmacists in the Emergency Department will be key driver in reducing medication errors. Workflow within the ED should be examined that address barriers to communication between all members of the healthcare team, minimize interruptions and distractions, and reduces verbal orders.

View the Poster (117KB).