Original Report| Volume 12, ISSUE 1, P29-40, January 2011

Analgesic Prescribing Errors and Associated Medication Characteristics


      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.


      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.

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      1. Anon. FDA Public Health Advisory. Important Information for the Safe Use of Fentanyl Transdermal System (Patch). FDA. Available at: Accessed June 10, 2010

      2. Aspden P. Wolcott J. Bootman J.L. Cronenwett L.R. The Committee on Identifying and Preventing Medication Errors. Preventing Medication Errors. Institute of Medicine of the National Academies. National Academies Press, Washington, D.C.2006
        • Barach P.
        • Small S.D.
        Reporting and preventing medical mishaps: Lessons from non-medical near miss reporting systems.
        BMJ. 2000; 320: 759-763
        • Bates D.W.
        • Cullen D.J.
        • Laird N.
        • Petersen L.A.
        • Small S.D.
        • Servi D.
        • Laffel G.
        • Sweitzer B.J.
        • Shea B.F.
        • Hallisey R.
        Vander Vliet M, Nemeskal R, Leape LL: Incidence of adverse drug events and potential adverse drug events. Implications for prevention.
        JAMA. 1995; 274: 29-34
        • Boockvar K.S.
        • Liu S.
        • Goldstein N.
        • Nebeker J.
        • Siu A.
        • Fried T.
        Prescribing discrepancies likely to cause adverse events after patient transfer.
        Qual Saf Hlth Care. 2009; 18: 32-36
      3. Cohen M. Medication Errors. 2nd ed. American Pharmaceutical Association, Washington, D.C.2007
        • Ferranti J.
        • Horvath M.M.
        • Cozart H.
        • Whitehurst J.
        • Eckstrand J.
        Reevaluation of the safety of pediatrics: A comparison of computerized adverse drug event surveillance and voluntary reporting in the pediatric environment. Pediatrics. 2008; 121: e1201-e1207
        • Kaushal R.
        • Bates D.W.
        • Abramson E.L.
        • Soukup J.R.
        • Goldmann D.A.
        Unit based clinical pharmacist's prevention of serious medication errors in pediatric inpatients.
        J Am Health-Sys Pharm. 2008; 65: 254-260
        • Kaushal R.
        • Bates D.W.
        • Landrigan C.
        • McKenna K.J.
        • Clapp M.D.
        • Federico F.
        • Goldman D.A.
        Medication errors and adverse drug events in pediatric inpatients.
        JAMA. 2001; 285: 2114-2120
        • Layde P.M.
        • Maas L.A.
        • Teret S.P.
        • Brasel K.J.
        • Kuhn E.M.
        • Mercy J.A.
        • Hargatan S.W.
        Patient safety efforts should focus on medical injuries.
        JAMA. 2002; 287: 1993-1997
        • Leape L.L.
        • Bates D.W.
        • Cullen D.J.
        • Cooper J.
        • Demonaco H.J.
        • Gallivan T.
        • Hallisey R.
        • Ives J.
        • Laird N.
        • Laffel G.
        • Nemeskal R.
        • Petersen L.A.
        • Porter K.
        • Servi D.
        • Shea B.F.
        • Small S.D.
        • Sweitzer B.J.
        Taylor Thompson B, Vander Vliet M: Systems analysis of adverse drug events.
        JAMA. 1995; 274: 35-43
        • Lee B.H.
        • Lehmann C.U.
        • Jackson E.V.
        • Kost-Byerly S.
        • Rothman S.
        • Kozlowski L.
        • Miller M.R.
        • Pronovost P.J.
        • Yasteret M.
        Assessing controlled substance prescribing errors in a pediatric teaching hospital: An analysis of the safety of analgesic prescription practice in the transition from hospital to home.
        J Pain. 2009; 10: 160-166
        • Leonard M.S.
        • Cimino M.
        • Shaha S.
        • Dougal S.
        • Pilliod J.
        • Brodsky L.
        Risk reduction for adverse drug events through sequential implementation of patient safety initiatives in a children's hospital.
        Pediatrics. 2006; 118: 1124-1129
        • Lesar T.
        Ten-fold medication dose prescribing errors.
        Ann Pharmacother. 2002; 36: 1833-1839
        • Lesar T.S.
        • Briceland L.L.
        • Stein D.L.
        Factors related to errors in medication prescribing.
        JAMA. 1997; 277: 312-317
        • Lesar T.S.
        • Lomaestro B.M.
        • Pohl H.
        Medication prescribing errors in a teaching hospital: A nine-year experience.
        Arch Intern Med. 1997; 157: 1569-1576
        • Lesar T.S.
        Errors in the use of medication dosage equations.
        Arch Pediatr Adolesc Med. 1998; 152: 340-344
        • Lesar T.S.
        Medication errors involving medication dosage formulations.
        J Gen Intern Med. 2002; 17: 579-587
        • Lesar T.S.
        Medication prescribing errors involving the route of administration.
        Hosp Pharm. 2006; 41: 1053-1066
        • McNeill J.A.
        • Sherwood G.D.
        • Starck P.L.
        The hidden error of mismanaged pain: A systems approach.
        J Pain Symptom Manage. 2004; 28: 47-58
        • McNutt R.A.
        • Abrams R.
        • Aron D.C.
        Patient safety efforts should focus on medical errors.
        JAMA. 2002; 287: 1997-2000
        • Miller M.R.
        • Robinson K.A.
        • Lubomski L.H.
        • Rinke M.L.
        • Pronovost P.J.
        Medication errors in paediatric care: A systematic review of epidemiology and an evaluation of evidence supporting reduction strategy recommendations.
        Qual Saf Hlth Care. 2007; 16: 116-126
        • Morss S.
        • Shore A.D.
        • Hicks R.W.
        • Morlock L.L.
        Medication errors with opioids: Results from a national reporting system.
        J Opioid Manage. 2007; 3: 189-194
        • O'Connor A.B.
        • Lang V.J.
        • Quill T.E.
        Underdosing of morphine in comparison with other parenteral opioids in an acute hospital: A quality of care challenge.
        Pain Med. 2006; 7: 299-307
        • Rogers A.E.
        • Dean G.E.
        • Hwang H.-T.
        • Scott L.D.
        Role of registered nurses in error prevention, discovery and correction.
        Qual Saf Hlth Care. 2008; 17: 117-121
        • Schiff G.D.
        • Galanter W.L.
        Promoting more conservative prescribing.
        JAMA. 2009; 301: 865-867
      4. Simmons D, Mick J, Graves K, Martin SK: 260000 close call reports: Lessons from the University of Texas Close Call Reporting System, in Advances in Patient Safety: New directions and alternative approaches. Available at: Accessed January 19, 2010

        • van Doormaal J.E.
        • van den Bent P.M.L.A.
        • Moi P.G.M.
        • Zaal R.J.
        • Egberts A.C.G.
        • Haaijer-Ruskamp F.M.
        • Kosternik J.G.W.
        Medication errors: The impact of prescribing and transcribing errors on preventable harm in hospitalized patients.
        Qual Saf Hlth Care. 2009; 18: 22-27
        • Wang J.K.
        • Herzog N.S.
        • Kaushal R.
        • Park C.
        • Mochizuki C.
        • Weingarten S.R.
        Prevention of pediatric medication errors by hospital pharmacists and the potential benefits of computerized physician order entry.
        Pediatrics. 2007; 119: e77-e85
        • Wolfstadt J.I.
        • Gurwitz J.H.
        • Field T.S.
        • Lee M.
        • Kalkar S.
        • Wu W.
        • Rochon P.A.
        The effect of computerized physician order entry with clinical decision support on the rates of adverse drug events: A systematic review.
        J Gen Intern Med. 2008; 23: 451-458