Use of Chart and Record Reviews to Detect Medication Errors in a State Psychiatric Hospital Benjamin C. Grasso, M.D. Robert Genest, R.Ph. Constance W. Jordan, M.S.N., A.N.P. David W. Bates, M.D., M.Sc.
Objective: This study compared the effectiveness of using a review team and the usual self-reporting method in detecting different types of medication errors in a state psychiatric hospital. Methods: Medication errors were defined by using widely accepted criteria. Rates of prescription, transcription, administration, and dispensing errors were determined, and the risk of harm from each error was rated as high, moderate, or low. A review team was assigned to retrospectively review 31 patient records for prescription, transcription, and administration errors for a total of 1,448 patient-days. Dispensing errors, which can only be determined concurrently, were reported for an equivalent number of patient-days. The error rate was compared with the rate that was determined by the usual method of self-reports from all nursing and medical staff. Results: In the 31 charts retrospectively reviewed and the dispensing events concurrently reviewed, the team detected a total of 2,194 medication errors, whereas a total of nine errors were self-reported for the same patient group. Administration errors accounted for more than half of the total (66 percent), followed by transcription errors (23 percent), prescription errors (11 percent), and dispensing errors (less than 1 percent). Nineteen percent of errors were rated as having a low risk of harm, 23 percent as having a moderate risk, and 58 percent as having a high risk. Conclusions: Use of a review team should be considered as a method for detecting and reporting medication errors. (Psychiatric Services 54:677–681, 2003)
D
espite the medical profession’s best efforts to provide safe and effective care, research has increasingly identified an alarming incidence of unintended harm to hospitalized patients. In the landmark 1991 Harvard Medical Practice Study, it was estimated that as many as 1.3 million injuries occur nationwide to patients receiving hospital care, with adverse drug events ac-
counting for 19 percent of all injuries (1,2). Subsequent research by Bates and colleagues (3–5) also found that medication errors are a significant cause of potential harm in adult general care settings. Their findings indicated that 28 percent to 56 percent of all adverse drug events that occur in such settings might have been prevented. The Institute of Medicine’s 1999 report (6) suggested that more deaths
Dr. Grasso and Ms. Jordan are affiliated with the Institute for Self-Directed Care, 95 India Street, Portland, Maine 04101 (e-mail,
[email protected]). Mr. Genest is with McKesson Medication Management. Dr. Bates is with Brigham and Women’s Hospital and Harvard Medical School in Boston.
PSYCHIATRIC SERVICES
♦ http://psychservices.psychiatryonline.org ♦ May 2003 Vol. 54 No. 5
occur annually from medication errors than from industrial accidents. Medication errors are also costly from a financial perspective. The national estimate of costs to hospitals is $2 billion per year, excluding malpractice costs and costs of injuries (7). However, most available data come from general care units. Few published studies have examined medication errors in psychiatric hospitals (8–10), and we could not find any that provide estimates of medication error rates or a systematic examination of error detection methodologies. We therefore undertook a study at a psychiatric institution and focused on improving the detection and reporting of medication errors, with an ultimate goal of decreasing their frequency. We have previously reported on our use of personal digital assistants (PDAs) in an attempt to decrease medication errors by increasing physician access to up-to-date patient medication profiles and to a pharmacology database (11). Errors in discharge medication lists have been reduced at our facility by the use of PDAs to directly print discharge medication lists using a printer with an infrared port, thereby nearly eliminating transcription errors at the time of discharge (12). However, at the time of the study reported here, all medication orders were written by hand in the usual fashion. Previous studies have found that the usual method of self-reporting errors may substantially underestimate 677
Table 1
Medication errors detected by review teams in a psychiatric hospital, by the criteria used for determining four types of errorsa Total number of errors
Type of error and criteria Prescription errors No route specified As-needed order without an indication Drug is indicated but the dose is inappropriate As-needed order without a time interval Dose change ordered without discontinuation of previous order Order is illegible Order is incomplete in specifying frequency Order is incomplete in specifying dose Transcription errors Order is not transcribed at all Order is transcribed incorrectly Allergy is not documented on the medication administration record Allergy status is not documented on the order sheet Administration errors Scheduled dose is not documented as administered Drug is administered without a physician order Dose missed because of late transcriptionb Order is incorrectly entered in the pharmacy computer Dispensing errors Medical technician errs in filling the medication cart Order is omitted in the pharmacy during computer order entry “Soft stop” order is incorrectly omitted in the pharmacy computer Pharmacy staff incorrectly fills an order a b
Percentage of category
Percentage of total
81 43 26 18 15 13 13 12
33.9 18.0 10.9 7.5 6.3 5.4 5.4 5.0
2.2 1.2 .7 .5 .4 .4 .4 .3
198 131 84 63
39.8 26.3 16.9 12.7
5.3 3.5 2.3 1.7
893 420 115 4
61.9 29.1 8.0 30
24.0 11.3 3.1
