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One in four hospital prescribing errors “potentially serious”

December 03, 2002

Around one in four hospital drug errors is “potentially serious,” and likely to harm patients, suggests a pilot study from one major teaching hospital, reported in Quality and Safety in Health Care.

Figures from the US indicate that up to 2% of hospital patients are harmed by drug errors, but there are few hard data for UK hospitals. None the less, the Department of Health has recommended that serious errors in the use of prescribed drugs be cut by 40% by 2005.

Pharmacists at a London teaching hospital recorded details of prescribing errors in all patients other than those in obstetric units over a period of four weeks in 1999.

During this time, 36,200 drug orders were written - almost 1300 a day. Mistakes were made in 1.5% - equivalent to 135 drug errors a week. Of these, one in four (34) was “potentially serious,” equivalent to 0.4% of all drug orders written, and say the authors, would have resulted in significant harm to the patients, had they not been intercepted.

Errors were more likely to be made during hospital stay (44%), rather than at the point of admission (32%) or discharge (15%), the study showed. But one in 10 occurred while transferring information onto new patient drug charts. Vascular surgery, renal, infectious disease and intensive care wards were the most frequent offenders.

Senior house officers made over half the errors (56%); junior house officers were responsible for one in three. Paracetamol, morphine, diamorphine, metoclopramide and beclomethasone were the drugs most likely to be the subject of error.

Almost four out of 10 of the errors involved the choice of drug, while almost two thirds (61%) involved the dose and/or timing of the drug.

While acknowledging that the volume of drug orders of one every 20 seconds means that it is impossible to eradicate all error, the authors point out that five potentially serious errors a day “is not acceptable.”

At the moment, the authors say, information on errors is only fed back to the prescriber, which means that it is not shared across the team, nor used to inform hospital-wide policy, and so allow comprehensive preventive strategies to be developed. This policy needs to be changed.

British Medical Journal (BMJ)