Drug errors made in 25% of hospitalized cardiovascular patients

Researchers recently reviewed the case histories of 24,538 patients who were admitted to cardiology wards and found an astonishing 4,768 pharmacist interventions that were related to medication errors – a total of nearly one in every four patients.

The most common errors included wrong drug (36%) or wrong dose (35.3%). Cardiovascular medications were involved in 41.2% of the errors recorded – a finding that is particularly alarming since most cardiovascular medications are extremely powerful and associated with severe adverse reactions.

The research was conducted by Nancy M. Allen LaPointe, Pharm.D., and James G. Jollins, M.D., of Duke University Medical Center, Durham, N.C.  The cases reviewed were taken from the cardiology wards at Duke University Hospital between September 1, 1995 and February 18, 2000.

“Three notable medication error trends were identified in our study, including: 1) a high number of errors attributed to lack of knowledge of the patient’s drug therapy before admission, 2) an increase in errors during periods of house staff transition, and 3) a gradual increase in the number of medication errors during the study period,” wrote the authors. They did not provide information on drug errors that would not caught by the pharmacist on duty at the hospital.

The researchers described two techniques for helping to reduce errors: “The first is the development of a system that provides health care providers with accurate, up-to-date medication information at the point of care. The second is more focused education and backup for new interns during their initial months of training. The large and increasing numbers of potential ADEs [adverse drug events] identified through routine review by a clinical pharmacist strongly support the role of pharmacists in assuring patient safety.”

SOURCE: “Medication Errors in Hospitalized Cardiovascular Patients,” by Nancy M. Allen LaPointe, Pharm.D; James G. Jollis, M.D. Archives of Internal Medicine. 2003;163:1461-1466 (June 23,2003).