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Chiropractic Research Review

One in Five Medication Doses in Error

In 1999, the Institute of Medicine released a report titled To Err is Human: Building a Safer Health System; this report investigated adverse drug events in hospitals and drew national attention.

Medication errors, such as incorrect dosage or time administered, may be of national concern, based on recent information.

A random sample of 36 hospitals accredited by the Joint Commission on Accreditation of Healthcare Organizations, non-accredited hospitals and "skilled nursing facilities" in Georgia and Colorado were observed for medication errors. Fifty day-shift doses per hospital
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unit, or all doses for a single medication pass, were examined by a research pharmacist, with any medication errors reaching patients recorded.

Results: One in five doses (19%) were incorrect; 7% of all dosages (37% of errors) were deemed potential adverse drug events, or potentially harmful to the patient. By category, the most frequent errors were: wrong time delivered (43%); omission of correct medication (30%); incorrect dosage (17%); or unauthorized drug given (4%).

The authors estimate that at an average of 10 dosages per patient per day, each patient would be administered approximately two incorrect medication errors each day.

Barker KN, Flynn EA, et al. Medication errors observed in 36 health care facilities. Archives of Internal Medicine 2002:162(16), pp. 1897-1903. http://archinte.ama-assn.org

Chiropractic Research Review

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