Analgesic Prescribing Errors and Associated Medication Characteristics

Abstract 

Medication errors involving analgesics, including mistakes in prescribing, are a major contributor to suboptimal therapeutic outcomes and preventable adverse patient events. A systematic evaluation of 2,044 prevented (near-miss) analgesic prescribing errors detected in a teaching hospital was performed to better understand these errors and contributing error-prone analgesic medication characteristics. The overall detected error rate was 2.87 errors per 1,000 analgesic orders, with the error rate more than twice as high in pediatric patients than in adults. Error rates varied widely between drugs, dosage forms, and routes of administration, but there was general consistency of error rates within drug groups with similar characteristics. Commonly prescribed medications were associated with the most errors, but less frequently prescribed agents had higher error rates. A number of factors were found to contribute to errors, and the following characteristics contributed to 40% of errors: availability in dose forms for multiple routes of administration; modified dosage forms; atypical dosage regimens; sound-alike drug names; and analgesics used on an ongoing scheduled basis.

Perspective

Identifiable analgesic product characteristics and uses are associated with higher risk for errors. The findings of this study can guide patient and caregiver education, and can be incorporated into medication safety strategies to reduce patient risk from analgesic errors.

Key words: Analgesics, prescribing, errors, adverse events, pharmacists