IV Drug Administration Errors by the Numbers

August 8, 2017 | Sean O'Neill and Parth Shah

Before we set out on a journey to create a solution to improve medication safety for some of the most dangerous drugs administered to patients, we sought to find out how big the problem really was—How many medication errors actually occur each year? In the world of medication errors, numbers often get thrown around without careful attention to where they come from. Numbers can be controversial, like the 1999 IOM report’s claims that medication errors cause up to 7,000 patient deaths each year and preventable medical errors as a whole cause up to 98,000. These numbers have been refuted by many as an underestimate, an overestimate, and just plain misleading.

The reality is, it is incredibly difficult to measure medication error rates. The vast majority of errors are not reported to medication error databases. One study estimated that only 12% of errors even meet state requirements for reporting. There is also tremendous variation by state. For example, while Pennsylvania receives hundreds of thousands of reports annually, other states receive as little as a few dozen. Although medication errors are unfortunately nearly ubiquitous, observing events that lead to significant patient harm requires research studies to have very large sample sizes. This is compounded by the fact that such observational studies are subject to the Hawthorne effect—if clinicians know that they are being observed, they are likely to change their practices.

Nonetheless, since the 1999 IOM report that first brought the problem of medication errors to the headlines, studies have overcome some of these challenges and provided insight into the incidence of medication errors. A large observational study of 113 ICUs estimated that a patient staying in the ICU for 4 days would face an average of 3 medication errors during the administration of IV drugs, and 1% of patients would experience permanent harm as a result. A review of 9 observational studies found that the probability of making a medication error during IV administration is 22%, and two studies found the probability to be higher (34% and 49%) for high alert drugs that are more likely to cause significant patient harm if not administered correctly. Another observational study of over 100 nurses found that almost 70% of IV administrations had a medication error, a quarter of which were assessed by clinicians as likely to lead to permanent harm.

While we may never know the exact incidence with which errors occur during the administration of IV drugs, the evidence is clear that it is a serious problem. The good news is that the use of technology in the medication administration process has increased dramatically in recent years with 84% of hospitals using computerized physician order entry, 94% using bar-coded medication administration, and over 81% using smart infusion pumps. But technology is not the silver bullet in the battle against medication errors. In fact, a recent report by the Pennsylvania Patient Safety Authority found that these health technologies were also a source of almost 1,000 medication errors over a six-month period. Humans interact with technologies, and this human-computer interface was implicated in 33% of reported technology-related errors. Implementing these recent innovations isn’t enough. Hospitals and safety leaders need tools to monitor these technologies to ensure that they are being used safely and appropriately. Our goal is to make medication safety easy to monitor, communicate and improve through technology and clinical expertise.

See published article here.

References

[1] Makary, Martin A. and Michael Daniel. “Medical Error—the Third Leading Cause of Death in the US | The BMJ.” Accessed June 22, 2017. http://www.bmj.com/content/353/bmj.i2139.

[2] McDonald, Clement J., Michael Weiner, and Siu L. Hui. “Deaths Due to Medical Errors Are Exaggerated in Institute of Medicine Report.” JAMA 284, no. 1 (July 5, 2000): 93–95. doi:10.1001/jama.284.1.93.

[3] Hanlon, Carrie, Kaitlin Sheedy, Taylor Kniffin, and Jill Rosenthal. “2014 Guide to State Adverse Event Reporting Systems.” National Academy for State Health Policy, January 2015. http://www.nashp.org/2014-guide-state-adverse-event-reporting-systems/.

[4] Valentin, Andreas, Maurizia Capuzzo, Bertrand Guidet, Rui Moreno, Barbara Metnitz, Peter Bauer, and Philipp Metnitz. “Errors in Administration of Parenteral Drugs in Intensive Care Units: Multinational Prospective Study.” BMJ 338 (March 13, 2009): b814. doi:10.1136/bmj.b814.

[5] McDowell, Sarah E., Shahrul Mt-Isa, Deborah Ashby, and R. E. Ferner. “Where Errors Occur in the Preparation and Administration of Intravenous Medicines: A Systematic Review and Bayesian Analysis.” Quality & Safety in Health Care 19, no. 4 (August 2010): 341–45. doi:10.1136/qshc.2008.029785.

[6] Taxis, K, and N Barber. “Causes of Intravenous Medication Errors: An Ethnographic Study.” Quality & Safety in Health Care 12, no. 5 (October 2003): 343–47. doi:10.1136/qhc.12.5.343.

[7] Wirtz, Veronika, Katja Taxis, and Nick D. Barber. “An Observational Study of Intravenous Medication Errors in the United Kingdom and in Germany.” Pharmacy World & Science: PWS 25, no. 3 (June 2003): 104–11.

[8] Westbrook, Johanna I., Marilyn I. Rob, Amanda Woods, and Dave Parry. “Errors in the Administration of Intravenous Medications in Hospital and the Role of Correct Procedures and Nurse Experience.” BMJ Qual Saf 20, no. 12 (December 1, 2011): 1027–34. doi:10.1136/bmjqs-2011-000089.

[9] Lawes, Staley, and Matthew Grissinger. “Medication Errors Attributed to Health Information Technology.” Pennsylvania Patient Safety Authority, March 2017. http://patientsafety.pa.gov:80/ADVISORIES/Pages/201703_HITmed.aspx.