Skip Navigation

This Article
Right arrow Full Text Freely available
Right arrow FREE Full Text (PDF) Freely available
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrow Search for citing articles in:
ISI Web of Science (6)
Right arrowRequest Permissions
Google Scholar
Right arrow Articles by ITO, H.
Right arrow Articles by YAMAZUMI, S.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by ITO, H.
Right arrow Articles by YAMAZUMI, S.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?

International Journal for Quality in Health Care 15:207-212 (2003)
© 2003 International Society for Quality in Health Care

Paper

Common types of medication errors on long-term psychiatric care units

HIROTO ITO1 and SYUN YAMAZUMI2

1Healthcare Evaluation Section, Department of Management Science, National Institute of Public Health, Wako, Saitama
2Hanazono Hospital, Yamanashi, Japan

Objective. This multi-center study identified the most frequent types of medication errors in long-term psychiatric care hospitals.

Setting. Japan.

Design and study participants. We asked 132 units in 44 Japanese psychiatric hospitals to introduce an in-patient incident reporting system on potential adverse drug events (PADEs) for the period 1 October to 30 November 2000. We analyzed types of PADE, outcomes, and characteristics of patients, staff, and units.

Results. We received 221 PADE incident reports from 85 units of 44 hospitals. One-quarter (24.9%) of the incidents were intercepted before reaching patients. The frequency of monitoring of the patients by clinical staff in response to medication errors increased by 8.1%. Wrong drug administration, i.e. giving a drug to a patient that was not the drug prescribed for that patient, was the most common type of incident (35.7%). Logistic regression analysis revealed that wrong drug administration occurred more frequently on units with either fewer registered nurses, or two or more patients with the same (or similar) name staying on the same unit. Incident reporters evaluated wrong drug administration as being potentially more serious than the other types of medication error. Wrong drug administration was seen more frequently in units with no patient name printed on medication drug pouches.

Conclusions. Wrong drug administration was the most common type of PADE, and may result in more serious consequences than others. Even a simple organizational quality improvement effort, in which printed patients’ names are placed on the drug pouch (not only with each prescription but with each drug administration), could reduce risk to patients from adverse outcomes due to medication errors.

Keywords: adverse drug event, drug administration, medication error, mental health, psychiatry, quality of care, safety


Add to CiteULike CiteULike   Add to Connotea Connotea   Add to Del.icio.us Del.icio.us    What's this?


This article has been cited by other articles:


Home page
 Int J Qual Health CareHome page
C. Haw, J. Stubbs, and G. Dickens
An observational study of medication administration errors in old-age psychiatric inpatients
Int. J. Qual. Health Care, August 1, 2007; 19(4): 210 - 216.
[Abstract] [Full Text] [PDF]

Home page
 Qual Saf Health CareHome page
I. D Maidment, P. Lelliott, and C. Paton
Medication errors in mental healthcare: a systematic review
Qual. Saf. Health Care, December 1, 2006; 15(6): 409 - 413.
[Abstract] [Full Text] [PDF]

Home page
 Psychiatr. Bull.Home page
I. D. Maidment and A. Thorn
A medication error reporting scheme: analysis of the first 12 months
Psychiatr. Bull., August 1, 2005; 29(8): 298 - 301.
[Abstract] [Full Text] [PDF]


Disclaimer: Please note that abstracts for content published before 1996 were created through digital scanning and may therefore not exactly replicate the text of the original print issues. All efforts have been made to ensure accuracy, but the Publisher will not be held responsible for any remaining inaccuracies. If you require any further clarification, please contact our Customer Services Department.