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Study of Medication Errors on a Community Hospital Oncology Ward

Intermountain Blood and Marrow Transplant Program and Departments of Nursing, Pharmacy, and Medicine, LDS Hospital, Salt Lake City, UT

Corresponding author: Clyde D. Ford, MD, Intermountain Blood and Marrow Transplant Program, LDS Hospital, 8th Ave and C St, Salt Lake City, UT 84143, clyde.ford{at}intermountainmail.com

PURPOSE: Medication errors (MEs) have been a significant problem resulting in excessive patient morbidity and cost, especially for cancer chemotherapeutic agents. Although some progress has been made, ME measurement methods and prevention strategies remain important areas of research.

METHODS: During a 2-year period (2003-2004), we conducted a prospective study on the oncology ward of a large community hospital, with the goals of (1) complete nurse reporting of observed medication administration errors (MAEs), (2) classifying observed MAEs, and (3) formulating improvement strategies. We also conducted a retrospective review of a randomly chosen sample of 200 chemotherapy orders to assess the appropriateness of ordering, dispensing, and administration.

RESULTS: Our nurses reported 141 MAEs during the study period, for a reported rate of 0.04% of medication administrations. Twenty-one percent of these were order writing and transcribing errors, 38% were nurse or pharmacy dispensing errors, and 41% were nurse administration errors. Only three MAEs resulted in adverse drug events. Nurses were less likely to report MAEs that they felt were innocuous, especially late-arriving medications from the pharmacy. A retrospective review of 200 chemotherapy administrations found only one clear MAE, a miscalculated dose that should have been intercepted.

CONCLUSIONS: Significant reported MAE rates on our ward (0.04% of drug administrations and 0.03 MAEs/patient admission) appear to be relatively low due to application of current safety guidelines. An emphasis on studying MAEs at individual institutions is likely to result in meaningful process changes, improved efficiency of MAE reporting, and other benefits.

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