Nature and frequency of medication errors in a geriatric ward: an Indonesian experience

Figures & data

Table 1 Definition of potential clinical consequences

Category	Definition	Definition of keywords
Potentially fatal	Medication errors judged to imply a potential clinical risk for causing the death of the patient	Fatal refers to medication errors that could lead to the death of the patient
Potentially serious	Medication errors judged to imply a potential clinical risk of injuring the patient	Injury includes medication errors that would require active treatment to restore the health of the patient. A potentially serious error would lead to either permanent or temporary disability
Potentially significant	Medication errors judged to imply a potential clinical risk of being inconvenient for the patient, without causing any harm or injury	Inconvenient refers to unpleasant consequences of wrong dose/drug or omission of dose/drug that could lead to symptoms such as pain or dizziness. It also refers to any monitoring of the patient such as extra blood tests, measurement of blood pressure
Potentially non-significant	Medication errors judged to be without any potential clinical risk for the patient	Without clinical risk refers to medication errors that did not lead to any injury or inconvenience for the patient

Note: Adapted from Lisby et al. Errors in the medication process: frequency, type, and potential clinical consequences. International Journal for Quality in Health Care. 2005;17(1):15–22. By permission of Oxford University Press.²⁰

Figure 1 Total number of medication errors identified in the medication delivery process.

Figure 2 Types and number of administration errors identified.

Figure 3 Types and number of transcription errors identified.

Figure 4 Types and number of dispensing errors identified.

Figure 5 Types and number of prescribing errors identified.

Table 2 Number of documentation errors identified based on Anatomy and Therapeutic Chemical (ATC) classification of medications

ATC main group classification	Medication administered but not documented as given (N=513)	Medication not administered, but documented as given (N=80)
Alimentary tract and metabolism	190	20
Cardiovascular system	81	25
Nervous system	54	13
Anti-infectives for systemic use	48	11
Respiratory system	40	2
Blood and blood-forming organs	29	4
Dermatologicals	23	–
General nutrients	19	1
Sensory organs	13	–
Antineoplastic and immunomodulating agents	9	2
Musculo-skeletal system	4	–
Various	3	2

Notes: – denotes no instances of this type of documentation error ‘Various’ refers to multivitamins. Based on ATC classification system for the medications groups.¹⁹

Table 3 Potential clinical outcomes of documentation errors and medication classes involved

Category	Errors N (%)	Identified medication groups
Potentially fatal	0	Nil identified
Potentially serious	14 (2.4%)	Anti-infective for systemic use (quinolones, beta-lactams, aminoglycosides); nervous system (antiepileptic drugs); blood and blood-forming organs (antiplatelet and anticoagulants)
Potentially significant	61 (10.3%)	Cardiovascular system (antihypertensive drugs, lipid modifying agents); alimentary tract and metabolism (drugs for peptic ulcers, antinauseants and antiemetics, drugs for constipation); nervous system (opioid analgesics, drugs indicated for analgesics and antipyretics)
Potentially non-significant	518 (87.4%)	Vitamin and mineral supplements

Notes: Potentially serious outcomes were calculated from all anti-infective systemic use, 1 anti-epileptic drug, 1 antiplatelet, and 1 anticoagulant. Meanwhile, potentially non significant outcomes were calculated based on medication administered but not documented (N=513), plus 1 general nutrient, 2 various (multivitamins), and 2 immunomodulating agents.

LisbyMNielsenLPMainzJErrors in the medication process: frequency, type, and potential clinical consequencesInt J Qual Health Care2005171152215668306

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