Updated 15 February 2013

Patients rarely told about medication errors

Patients and their families are rarely told when hospitals make mistakes with their medicines, according to a new study.


Patients and their families are rarely told when hospitals make mistakes with their medicines, according to a new study.

Most medication mistakes did not harm patients, the researchers found, but those that did were more likely to happen in intensive care units. And ICU patients and families were less likely to be told about errors than patients in other units.

"For the most part, our findings were in keeping with what the existing literature tells us about the where and how of medication errors in a hospital," wrote Dr Asad Latif, the study's lead author, in an email.

"The most surprising finding was what we do about them, at least in the immediate time around when they occur," added Dr Latif, from the Johns Hopkins University School of Medicine in Baltimore.

How the research was done

Using data on nearly 840 000 voluntarily reported hospital medication errors from 537 US hospitals between 1999 and 2005, the researchers found that ICUs accounted for about 56 000, or 6.6%, of the errors.

The vast majority of the mistakes - about 98% - didn't lead to a patient being harmed, but those that did were more likely to happen in the ICUs, the researchers reported.

About 4% of errors in ICUs ended up harming a patient, compared with about 2% of errors outside the ICU.

In ICUs and non-ICUs, errors of omission - failing to give a patient the medication - were most common. Harmful errors most often involved devices like IV lines and mistakes in calculating medication dosages.

Reducing mistakes

More than half of the time, no actions were taken after an error. In fact, only a third of the hospital staff who made the reported mistakes were immediately told about their errors.

"And the patient and/or their family is immediately informed when an error occurs barely 2% of the time, despite literature supporting full disclosure and their desire to be promptly informed," Dr Latif said.

"Studies like this give us the opportunity to find out how we are actually doing, compared to how we think we are doing," he said. "They help us discover associations between the outcomes we are interested in and their potential causes and consequences."

Research has found that instituting a blame-free reporting system in hospitals increases the number of reported mistakes.

According to the new paper, one prior study demonstrated that medication errors can add an extra $2.8 million in costs at a single hospital.

Dr Latif added the healthcare system is always trying to reduce medication mistakes. "However nothing is fool-proof as we show in our study; there is always the human factor to take into account. The key is what we do if they do happen and to keep striving for perfection," Dr Latif said.

(Reuters Health, January 2013)

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