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
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Article info
Publication history
Published online: June 18, 2010
Accepted:
April 21,
2010
Received in revised form:
March 19,
2010
Received:
January 15,
2010
Identification
Copyright
© 2011 American Pain Society. Published by Elsevier Inc. All rights reserved.
