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Examination of Medication Errors Occurring in the Patient's Home Reported to USP's Medication Error Reporting Programs

U.S. Pharmacopeia, Rockville, MD
Center for the Advancement of Patient Safety
Susan Camp, PharmD and Rodney Hicks, RN, MSN, MPA

Presented Monday, March 29, 2004
American Pharmacists Association
Annual Meeting 2004, Seattle, WA

Purpose

To understand the characteristics of medication errors occurring in the patient's home. This understanding can contribute to the development of strategies to improve the safe use of medications. From these data, we hope to identify safe practices that healthcare professionals and consumers can use to prevent errors from occurring in the patient's home. The findings from this study will be utilized by USP's Safe Medication Use Expert Committee to develop practice recommendations for healthcare professionals and/or safe medication use recommendations for consumers.

Methodology

Reports where the location of the error was identified as the patient's home were analyzed from MEDMARX® and the USP Medication Errors Reporting (MER) Program*. Structured queries were performed to present information about the Severity, Node (where in the medication use process the errors initiated), Type, Cause, Contributing Factor, Product, and Level of Staff involved in the error. The actions taken and recommendations in response to the errors were also reviewed for recurring medication use problems and solutions.

Results

Medication errors occurring in the patient's home resulted in some form of harm to the patient 11% (87/802) of the time. When compared to prior USP studies, this study found that Extra dose (12%) was more frequently reported as a Type of Error; Communication (21%), Knowledge deficit (19%), and Monitoring inadequate/lacking (4%) were recurring Causes; No access to patient information (10%) was reported more frequently as a Contributing Factor; and warfarin (9%) was the product most frequently associated with medication errors. Some of the recommendations that healthcare professionals reported include establishing better communication and patient counseling processes; creating easier programming features for IV pumps; and encouraging patients to inquire if something is different or does not appear right when being administered a medication or taking ones own medication.

Observations/Conclusions

It is apparent from these data that adequate education and training, as well as proper communication, are integral parts in improving patient outcomes in the home. In many cases, patients did not understand how to take their medication, or did not ask questions when something about the medication was different or did not seem right. If healthcare professionals expect to have an impact on improved outcomes in the patient's home, patient counseling processes must be improved.

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