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Kenneth N. Barker, PhD; Elizabeth A. Flynn, PhD; Ginette A. Pepper, PhD; David W. Bates, MD, MSc; Robert L. Mikeal, PhD

Arch Intern Med. 2002;162:1897-1903.

Background  Medication errors are a national concern.

Objective  To identify the prevalence of medication errors (doses administered differently than ordered).

Design  A prospective cohort study.

Setting  Hospitals accredited by the Joint Commission on Accreditation of Healthcare Organizations, nonaccredited hospitals, and skilled nursing facilities in Georgia and Colorado.

Participants  A stratified random sample of 36 institutions. Twenty-six declined, with random replacement. Medication doses given (or omitted) during at least 1 medication pass during a 1- to 4-day period by nurses on high medication–volume nursing units. The target sample was 50 day-shift doses per nursing unit or until all doses for that medication pass were administered.

Methods  Medication errors were witnessed by observation, and verified by a research pharmacist (E.A.F.). Clinical significance was judged by an expert panel of physicians.

Main Outcome Measure  Medication errors reaching patients.

Results  In the 36 institutions, 19% of the doses (605/3216) were in error. The most frequent errors by category were wrong time (43%), omission (30%), wrong dose (17%), and unauthorized drug (4%). Seven percent of the errors were judged potential adverse drug events. There was no significant difference between error rates in the 3 settings (P = .82) or by size (P = .39). Error rates were higher in Colorado than in Georgia (P = .04)

Conclusions  Medication errors were common (nearly 1 of every 5 doses in the typical hospital and skilled nursing facility). The percentage of errors rated potentially harmful was 7%, or more than 40 per day in a typical 300-patient facility. The problem of defective medication administration systems, although varied, is widespread.

From the Center for Pharmacy Operations and Designs, School of Pharmacy, Auburn University, Auburn, Ala (Drs Barker and Flynn); the School of Nursing, University of Colorado Health Sciences Center, Denver (Dr Pepper); the Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, and the Center for Applied Medical Information Systems, Partners Healthcare and Harvard Medical School, Boston, Mass (Dr Bates); and DACE Co, West Monroe, La (Dr Mikeal).

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