Non-health care facility medication errors resulting in serious medical outcomes

Abstract

Objective: The objective of this study is to provide an epidemiologic analysis of medication errors occurring outside of health care facilities that result in serious medical outcomes (defined by the National Poison Database System as “moderate effect,” “major effect,” “death,” or “death, indirect report”).

Methods: National Poison Database System data from 2000 through 2012 were used for this retrospective analysis of non-health care facility medication errors.

Results: From 2000 through 2012, Poison Control Centers in the United States received data on 67,603 exposures related to unintentional therapeutic pharmaceutical errors that occurred outside of health care facilities that resulted in serious medical outcomes. The overall average rate of these medication errors was 1.73 per 100,000 population, and there was a 100.0% rate increase during the 13-year study period. Medication error frequency and rates increased for all age groups except children younger than 6 years of age. Medical outcome was most commonly reported as moderate effect (93.5%), followed by major effect (5.8%) and death (0.6%). Common types of medication errors included incorrect dose, taking or administering the wrong medication, and inadvertently taking the medication twice. The medication categories most frequently associated with serious outcomes were cardiovascular drugs (20.6%) (primarily beta blockers, calcium antagonists, and clonidine), analgesics (12.0%) (most often opioids and acetaminophen, alone and combination products), and hormones/hormone antagonists (11.0%) (in particular, insulin, and sulfonylurea).

Conclusions: This study analyzed non-health care facility medication errors resulting in serious medical outcomes. The rate of non-health care facility medication errors resulting in serious medical outcomes is increasing, and additional efforts are needed to prevent these errors.

Keywords:

• Medication error
• NPDS
• poisoning
• Poison Control Center

Disclosure statement

The authors have no conflicts of interest relevant to this study.

The inferences and conclusions expressed by the authors of this study do not necessarily represent those of the AAPCC or its member centers.

Additional information

Funding

The authors have no financial disclosures relevant to this study.