Public Release: 

USP releases fourth annual report on medication errors in U.S. hospitals

More than one-third of hospital medication errors that reach the patient involve seniors

US Pharmacopeia

Rockville, Md., Nov. 18, 2003--The United States Pharmacopeia (USP) today released its fourth annual national report summarizing the most recent data collected by MEDMARXSM, the anonymous national medication error reporting database operated by USP. Among the highlights: more than one-third of hospital medication errors that reach the patient involve seniors--showing they continue to be a vulnerable population in U.S. health care facilities.

MEDMARX helps hospitals report, understand and ultimately prevent medication errors in hospitals. The MEDMARX data report, Summary of Information Submitted to MEDMARX in the Year 2002: The Quest for Quality, provides a comprehensive analysis of 192,477 medication errors as voluntarily reported by 482 hospitals and health care facilities nationwide, including community, government and teaching institutions. MEDMARX is the nation's largest database of medication errors, containing more than 530,000 released records. By the end of the third quarter of 2004, the number of records in the MEDMARX database will approach one million.

MEDMARX is a national, Internet-accessible anonymous reporting database that hospitals and health care systems use to track and trend medication errors. Hospitals and health care systems participate in MEDMARX voluntarily. USP created MEDMARX to help health care facilities understand the causes of medication errors and the factors that contribute to them in order to improve patient care and safety.

Seniors at Greater Risk of Hospital Medication Errors

"The report data revealed that more than one-third of the medication errors reaching the patient involved a patient aged 65 or older," said Diane Cousins, R.Ph., vice president of the Center for the Advancement of Patient Safety (CAPS) at USP. "As the senior population continues to increase, USP is calling for hospitals to focus on reducing medication errors among seniors. Seniors and their families need to become more involved in their care."

Specifically with reference to the senior population, the 2002 MEDMARX data report revealed a number of significant findings, including:

  • A majority (55 percent) of fatal hospital medication errors reported involved seniors.
  • When medication errors caused harm to seniors 9.6 percent were prescribing errors.
  • Wrong route (7 percent), such as a tube feeding given intravenously, and wrong administration technique (6.5 percent), such as not diluting concentrated medications, were the second and third most common errors among those aged 65 and over.
  • Omission errors (43 percent), improper dose/quantity errors (18 percent), and unauthorized drug errors (11 percent) were the most common types of medication errors among seniors.

More Error Reporting Helps Reduce Patient Harm and Injury

"We are seeing a strong upsurge in the number of medication errors in the database," Cousins said. "This increase is a positive step toward identifying and eliminating medication errors and ensuring the safety and well-being of all hospital patients. By identifying medication error trends and problem areas, hospitals will be able to prevent future errors and reduce patient harm and injuries."

Of the 192,477 medication errors documented by MEDMARX, the vast majority were corrected before causing harm to the patient. However, 3,213 errors, or 1.7 percent of the total, resulted in patient injury. Of this number, 514 errors required initial or prolonged hospitalization, 47 required interventions to sustain life, and 20 resulted in a patient's death. Compared with 2001 data, a smaller percentage of reported errors resulted in harm to the patient (1.7 percent in 2002 versus 2.4 percent in 2001).

The 2002 MEDMARX data report also found that incorrect administration technique continues to be responsible for the largest number of harmful medication errors (6.2 percent). This occurs when medications are either incorrectly prepared or administered, or both. Examples include not diluting concentrated medications, crushing sustained-released medications, wrong eye application of eye drops, and using incorrect IV tubes for medicine administration.

Health care facilities attributed medication errors to many reasons and often cited workplace distractions (43 percent), staffing issues such as shift changes and floating staff (36 percent), and workload increases (22 percent), as contributing factors. Although workplace distraction remains the leading factor contributing to medication errors, the data revealed a drop from 47 percent in 2001.

A limited number of high-alert medications continue to cause the most severe injury to patients when an error is committed. For example, three of the top medications frequently involved in harmful errors were insulin, heparin, and morphine. For more information on medication errors for high-alert medications, please see the USP fact sheet High-Alert Medications in 2002 at http://www.usp.org/newscenter.

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For more information on MEDMARX, to receive a copy of the 2002 data report, or to request MEDMARX b-roll, send an e-mail to mediarelations@usp.org. A Webcast presentation on the MEDMARX report findings will take place on Tuesday, November 18, 2003, at 11:00 a.m. EST. To register, send an e-mail to mediarelations@usp.org .

USP--Advancing Public Health Since 1820
The United States Pharmacopeia (USP) is a nonprofit, nongovernmental, standard-setting organization that advances public health by ensuring the quality and consistency of medicines, promoting the safe and proper use of medications, and verifying ingredients in dietary supplements. These standards, which are recognized worldwide, are developed by a unique process of public involvement through the contributions of volunteers representing pharmacy, medicine, and other health care professions, as well as science, academia, government, the pharmaceutical industry, and consumer organizations. For more information about USP and its four public health programs, visit http://www.usp.org/newscenter.

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