Database tracks causes of hospital medication errors

U.S. Pharmacopeia is looking to build its voluntary medication errors database into a tool that can be used to stem such mistakes in hospitals.

By Linda O. Prager, AMNews staff. Jan. 15, 2001.

Staffers' distractions, heavy work loads and inexperience are the chief culprits behind medication errors in hospitals, according to a report released last month.

In its first year operating an anonymous error-reporting system, the nonprofit U.S. Pharmacopeia, Rockville, Md., garnered 1999 data on 6,224 medication errors from 56 hospitals. The vast majority of those errors weren't harmful, even though more than two-thirds weren't intercepted before reaching the patient. But 3% caused temporary or permanent impairment requiring intervention, and some were life-threatening or fatal.

Those who may take solace in those numbers, however, should recognize that they "show just the tip of the iceberg," said Roger L. Williams, MD, the private-sector group's executive vice president and CEO.

The data reflect voluntary reporting from only about 1% of hospitals. Previous studies suggest that such reporting picks up only about one in 20 events, noted David Bates, MD, chief of general medicine at Brigham and Women's Hospital, Boston. The database also provides no hints on the prevalence, causes and ramifications of errors in outpatient settings, where most medication use takes place.

In its controversial report on medical errors, the Institute of Medicine estimated that medication errors annually account for up to 7,000 deaths in the United States. If USP data were available systemwide, it likely would show similar numbers, Dr. Williams suggested. Regardless of the overall statistics, he said, "any level of error is intolerable and should lead to a search for systemic solutions." [...]