Skip to main content
Log in

Occurrence of Dispensing Errors and Efforts to Reduce Medication Errors at the Central Arkansas Veteran’s Healthcare System

  • Short Communication
  • Published:
Drug Safety Aims and scope Submit manuscript

Abstract

Background: Medical errors have received national attention in the past few years, largely due to the Institute of Medicine’s (IOM) 1999 report, which found that over one million injuries and nearly 100 000 deaths occur annually in the US as a result of medical errors.

Purpose: The purpose of this study was to examine the type and severity of dispensing errors reported by pharmacy services at the Central Arkansas Veteran’s Healthcare System from October 1997 through September 2001 and to examine the efforts implemented by the Central Arkansas Veteran’s Healthcare System to reduce overall medication-related errors.

Methods: Dispensing error reports for the Central Arkansas Veteran’s Healthcare System were obtained for October 1997 to September 2001. Dispensing errors were tabulated in the Statistical Package for the Social Sciences (SPSS) according to the pharmacy section, type of error (wrong drug, wrong dose, wrong patient and ‘other’) and severity of error (minor, significant, major and unrated). Data were explored using descriptive statistics, χ2, independent sample t-tests and Pearson’s correlation. Information on error reduction efforts was obtained from pharmacy administrative services.

Results: A total of 82 dispensing errors were reported from eight different pharmacy sections for the time period examined. Errors included 31 wrong drugs, 21 wrong doses, 24 wrong patients and six ‘other’ errors. The number of errors, according to severity, included 29 unrated, 30 minor, 21 significant and two major errors. Both major errors were due to wrong drug selection. In total, the highest number of errors occurred at the North Little Rock Ambulatory Care Pharmacy (39 errors) and the Little Rock Ambulatory Care Pharmacy (24 errors).

Wrong drug and wrong dose dispensing errors were not significantly different among the pharmacy sections. Wrong patient selection was significantly different among pharmacy service sections. Wrong patient selection, wrong drug, and wrong dose were all significantly correlated with unrated severity, minor severity, and significant severity. Significant correlations were also found between wrong drug, wrong dose and wrong patient selection. There were no significant correlations between wrong patient selection and major severity, or other errors. χ2 analysis found significant differences in expected frequency among errors for wrong drug, wrong dosage, wrong patient and other errors. Significant differences were also found in expected frequencies between unrated, minor, significant and major errors.

Discussion: Although the major dispensing errors were not statistically different according to pharmacy services sections and not significantly correlated with any other categories, they both involved the selection of the wrong drug, which was also the most common error. In contrast, the selection of the wrong patient, the second most common error, was statistically different among pharmacy sections and was significantly correlated with all other dispensing type and severity of error except major severity and other errors.

Conclusion: Focusing error reduction efforts on selection of the correct drug and correct patient would likely yield the best results in reducing dispensing errors since these errors combined accounted for 55 (67.1%) of the 82 reported errors.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Table I
Table II
Table III
Table IV

Notes

  1. The use of trade names is for product identification purposes only and does not imply endorsement.

References

  1. Kohn KT, Corrigan JM, Donaldson MS, editors. To err is human: building a safer health system. Washington, DC: Committee on Quality of Health Care in America, Institute of Medicine, National Academy Press, 1999

  2. Leape LL, Berwick DM, Bates DW. What practices will most improve safety? Evidence-based medicine meets patient safety. JAMA. 2002 July; 288(4): 501–507

    Article  PubMed  Google Scholar 

  3. Voelker R. Hospital collaborative creates tools to help reduce medication errors. JAMA 2001 Dec; 286(24): 3067–9

    Article  PubMed  CAS  Google Scholar 

  4. Flynn EA, Barker KN, Pepper GA, et al. Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities. Am J Health Syst Pharm 2002 Mar; 59(5): 436–46

    PubMed  Google Scholar 

  5. Young D. More hospitals report medication errors, but USP finds few changes. Am J Health Syst Pharm 2002 July; 59(13): 1233

    PubMed  Google Scholar 

  6. Bates DW, Leape LL, Cullen DJ, et al. Effect of computerized physician order entry and team intervention on prevention of serious medication errors. JAMA 1998 Oct; 280(15): 1311–6

    Article  PubMed  CAS  Google Scholar 

  7. The United States Pharmacopeial Convention. National Coordinating Council for Medication Error Reporting and Prevention. Definition of medication errors [online]. Available from URL: http://www.usp.org/reporting/review/rev_057.htm [Accessed 1997 Jan]

  8. Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients: results from the Harvard Medical Practice Study I. N Engl J Med 1991; 324: 370–6

    Article  PubMed  CAS  Google Scholar 

  9. Lesar TS, Lomaestro BM, Pohl H. Medication prescribing errors in a teaching hospital. a 9-year experience. Arch Intern Med 1997; 157: 1569–76

    Article  PubMed  CAS  Google Scholar 

  10. Raju TN, Kecskes S, Thornton JP, et al. Medication errors in neonatal and pediatric intensive care units. Lancet 1989; 12: 374–6

    Article  Google Scholar 

  11. Lesar TS, Briceland LL, Delcoure K, et al. Medication prescribing errors in a teaching hospital. JAMA 1990; 263: 2329–34

    Article  PubMed  CAS  Google Scholar 

  12. Calliari D. The relationship between a calculation test given in nursing orientation and medication errors. J Contin Educ Nurs 1995; 26: 11–4

    PubMed  CAS  Google Scholar 

  13. Rowe C, Koren T, Koren G. Errors by pediatric residents in calculating drug doses. Arch Dis Child 1998; 79: 56–8

    Article  PubMed  CAS  Google Scholar 

  14. Leape LL, Bates DW, Cullen DJ, et al. Systems analysis of adverse drug events. JAMA 1995; 274: 35–43

    Article  PubMed  CAS  Google Scholar 

  15. Cohen MR, Anderson RW, Attilio RM, et al. Preventing medication errors in cancer chemotherapy. Am J Health Syst Pharm 1996; 53: 737–46

    PubMed  CAS  Google Scholar 

  16. Allard J, Carthery J, Cope J, et al. Medication errors: causes, prevention and reduction. Br J Haematol 2002 Feb; 116(2): 255–65

    Article  PubMed  Google Scholar 

  17. Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drug events. JAMA 1995; 274: 29–34

    Article  PubMed  CAS  Google Scholar 

  18. Ross LM, Wallace J, Paton JY. Medication errors in a pediatric teaching hospital in the UK: five years operational experience. Arch Dis Child 2000; 83: 492–7

    Article  PubMed  CAS  Google Scholar 

  19. Edgar TA, Lee DS, Cousins DD. Experience with a national medication error reporting programme. Am J Health Syst Pharm 1994; 51: 1335–8

    CAS  Google Scholar 

  20. The United States Pharmacopeial Convention. National coordinating council for medication error reporting and prevention. medication error index [online]. Available from URL: http://www.usp.org/reporting/review/rev_057g.htm [Accessed 1997 Jan]

  21. Hartwig SC, Denger SD, Schneider PJ. Severity-indexed, incident report-based medication error-reporting program. Am J Hosp Pharm 1991; 48: 2611–6

    PubMed  CAS  Google Scholar 

  22. Shojania K, Duncan B, McDonald K, et al., editors. Making health care safer: a critical analysis of patient safety practices. Rockville (MD): Agency For Healthcare Research and Quality; 2001. Evidence Report/Technology Assessment No. 43; AHRQ Publication 01-E058

  23. Massachusetts Coalition for the Prevention of Medical Errors. MHA best practice recommendations to reduce medication errors. Burlington (MA): Coalition for the Prevention of Medical Errors; 2001 [online]. Available from URL: http://www.mhalink.org/mcpme/mha_best_practice_recommendation.htm

  24. American Hospital Association. AHA initiative: improving medication safety. Chicago (IL): American Hospital Association, 2002

  25. Pederson CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: dispensing and administration 2002. Am J Health Syst Pharm 2003 Jan; 60(1): 52–68

    Google Scholar 

  26. Olsen KM. Medication errors: problems identified, but what is the solution? Crit Care Med 2002 Apr; 30(4): 944–5

    Article  PubMed  Google Scholar 

  27. Lee P. Ideal principles and characteristics of a fail-safe medication-use system. Am J Health Syst Pharm 2002 Feb; 59(4): 369–71

    PubMed  Google Scholar 

  28. Hronek C, Bleich MR. The less-than-perfect medication system: a systems approach to improvement. J Nurs Care Qual 2002 Jul; 16(4): 17–22

    Article  PubMed  Google Scholar 

  29. United States General Accounting Office. VA and Defense Health Care. Increased risk of medication errors for shared patients. Report to the Chairman, Subcommittee on Defense, Committee on Appropriations, US Senate. GAO Publication GAO-02-1017. 2002 Sep

  30. Computerized provider order entry systems. Health Devices 2001 Sep; 30 (9–10): 323–59

  31. Scalise D. CPOE: an executive’s guide. Hosp Health Netw 2002 Jun; 76(6): 41–6

    PubMed  Google Scholar 

  32. Kuperman GJ, Teich JM, Gandhi TK, et al. Patient safety and computerized medication ordering at Brigham and Women’s Hospital. Jt Comm J Qual Improv 2001 Oct; 27(10): 509–21

    PubMed  CAS  Google Scholar 

  33. Chan W. Increasing the success of physician order entry through human factors engineering. J Healthc Inf Manag 2002 Winter; 16(1): 71–79

    PubMed  Google Scholar 

  34. Sittig DF, Stead WW. Computer-based physician order entry: the state of the art. J Am Med Inform Assoc 1994 March; 1(2): 108–123

    Article  PubMed  CAS  Google Scholar 

  35. Teich JM, Merchia PR, Schmiz JL, et al. Effects of computerized physician order entry on prescribing practices. Arch Intern Med 2000 Oct; 160(18): 2713–4

    Article  Google Scholar 

  36. Lee YL, Hsu CY, Hsieh D, et al. Development and deployment of a web-based physician order entry system. Int J Med Inf 2001 Jul; 62(2-3): 135–42

    Article  CAS  Google Scholar 

  37. Eskew A, Geisler M, O’Connor L, et al. Enhancing patient safety: clinician order entry with a pharmacy interface. J Healthc Inf Manag 2002 Winter; 16(1): 52–7

    PubMed  Google Scholar 

  38. Ahmad A, Teater P, Bentley TD, et al. Key attributes of a successful physician order entry system implementation in a multi-hospital environment. J Am Med Inform Assoc 2002 Jan; 9(1): 16–24

    Article  PubMed  Google Scholar 

  39. Bates DW, Teich JM, Lee J, et al. The impact of computerized physician order entry on medication error prevention. J Am Med Inform Assoc 1999 Jul; 6(4): 313–21

    Article  PubMed  CAS  Google Scholar 

  40. Lovis C, Payne TH. Extending the VA CPRS electronic patient record order entry system using natural language processing techniques. Proc AMIA Symp 2000, 521

    Google Scholar 

  41. Chin Hl, Wallace P. Embedding guidelines into direct physician order entry: simple methods, powerful results. Proc AMIA Symp 1999, 225

    Google Scholar 

  42. Leape LL, Cullen DJ, Clapp MD, et al. Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. JAMA 1999; 282: 267–70

    Article  PubMed  CAS  Google Scholar 

  43. Thompson CA. FDA to develop rules for mandatory bar-code labels: bar codes seen as part of error-reduction strategy. Am J Health Syst Pharm 2002 Jan; 59(2): 107–12

    PubMed  Google Scholar 

  44. Thompson KK. Bar coding a must for patient safety. Am J Health Syst Pharm 2002 Apr; 59(7): 667–8

    Google Scholar 

  45. Young D. Veterans affairs-bar-code-scanning system reduces medication errors. Am J Health Syst Pharm 2002 Apr; 59(7): 591–2

    PubMed  Google Scholar 

  46. Rios E, Hix M, Patel M. BCMA: meeting the challenges ahead. Poster Presentation. Arkansas Association of Health-System Pharmacists 2002 Annual Meeting; 2002 Oct, Hot Springs (AR)

  47. Central Arkansas Veteran’s Healthcare System. Memorandum 00-61 patient safety improvement program. Little Rock (AR): CAVHS, 2001 Dec 18

  48. JCAHO. Sentinel event policy [online]. Available from URL: http://www.jcaho.org/accredited+organizations/hospitals/sentinel+events/se_pp.htm [Accessed 2004 Jan]

  49. Bond CA, Raehl CL, Franke T. Medication errors in United States hospitals. Pharmacotherapy 2001; 21(9): 1023–36

    Article  PubMed  CAS  Google Scholar 

  50. Bond CA, Raehl CL, Franke T. Clinical pharmacy services, hospital pharmacy staffing, and medication errors in United States hospitals. Pharmacotherapy 2002; 22(2): 134–47

    Article  PubMed  CAS  Google Scholar 

  51. Ogden JE, Muniz A, Patterson AA, et al. Pharmaceutical services in the department of veterans affairs. Am J Health Syst Pharm 1997 Apr; 54(7): 761–5

    PubMed  CAS  Google Scholar 

Download references

Acknowledgments

I would like to thank Don Johnson, M.S., Pharm.D. Director of Pharmacy Services, Holly Rickman, M.S., Pharm.D. Education/QM Coordinator, Ralph Watson, R.Ph. Director of Inpatient Pharmacy Services and Bill Kemp, R.Ph. Director of Outpatient Pharmacy Services for their assistance in clarifying policies, procedures and systems for reporting, tracking, evaluating, intervening and correcting medication errors at Central Arkansas Veteran’s Healthcare System.

No sources of funding were used to assist in the preparation of this study. The author has no conflicts of interest that are directly relevant to the content of this manuscript.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Philip Rolland.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Rolland, P. Occurrence of Dispensing Errors and Efforts to Reduce Medication Errors at the Central Arkansas Veteran’s Healthcare System. Drug-Safety 27, 271–282 (2004). https://doi.org/10.2165/00002018-200427040-00004

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.2165/00002018-200427040-00004

Keywords

Navigation