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Prescribing errors are the most common medication errors in primary care practices

Research Activities, February 2009, No. 374

Most of the medication errors in primary care practices are prescribing errors, and more than half of these errors reach patients, concludes a new study. Electronic tools are necessary to reduce the rate of errors and subsequent harm (adverse drug events or ADEs) to patients, suggest the study authors. Studies of medication errors have typically been conducted in hospitals, rather than in primary care settings. To understand the nature of medication errors in primary care settings, the American Academy of Family Physicians (AAFP) Research Network and the AAFP Robert Graham Policy Center looked at medication error reports from two studies conducted in the network.

The researchers combined reports of medication errors from a 20-week medical error study involving 42 family physicians at 42 practices with those from a 10-week study involving 401 clinicians and staff from 10 diverse family medicine offices. Of a total of 1,265 medical errors reported, 194 reports concerned errors in medication. Seventy percent of the medication error reports involved prescribing errors, 10 percent each involved medication administration or documentation errors, 7 percent involved errors in dispensing drugs, and 3 percent involved medication monitoring errors. In 41 percent of the reports, the errors were prevented and did not reach the patients, while 59 percent reached the patient 35 percent did not require monitoring. Monitoring was required in 8 percent of the reports, intervention in 13 percent, and hospitalization of affected patients in 3 percent). Although 16 percent of the medication errors were ADEs, none of the errors resulted in permanent harm or a patient's death.

Pharmacists were most likely to prevent the errors from reaching the patients (40 percent of intercepted medication errors), while physicians and patients were almost equally likely to intercept the medication error (19 percent and 17 percent of intercepted errors, respectively). The researchers determined that more widespread use of heath care information technology, such as electronic medical records or computer physician order entry systems, could have prevented as many as 57 percent of the medication errors. The study was funded in part by the Agency for Healthcare Research and Quality (HS11584 and HS14552).

More details are in "Medication errors reported by US family physicians and their office staff," by Grace M. Kuo, Pharm.D., M.P.H., Robert L. Phillips, M.D., M.S.P.H., Deborah Graham, M.S.P.H., and John M. Hickner, M.D., M.Sc., in Quality and Safety in Health Care 17, pp. 286-290, 2008.

Current as of February 2009
Internet Citation: Prescribing errors are the most common medication errors in primary care practices: Research Activities, February 2009, No. 374. February 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://archive.ahrq.gov/news/research-activities/feb09/0209RA5.html