Analysis of Medication Errors of Health Care Providers on the Basis of Data from the Czech Toxicological Information Centre over an 11-Year Period (2000-2010)
Abstrakt
This study aimed to analyse medication errors committed by health care professionals leading to toxicological consultations at the Czech Toxicological Information Centre and to identify the categories of special concern for further interventions of health care quality experts. From the Toxicological Information Centre (TIC) database, 44,344 calls concerning drug application were studied retrospectively over the period of 2000-2010.
The calls regarding medication errors caused by mistakes of the health care personnel were identified and analysed. From 215 calls regarding medication errors, 130 involved children (90 below 5 years of age) and 85 adults (30 over 60 years of age).
Of 25 patients with severe drug intoxications, 60.0% were children under 5 years of age with parenteral administration of the pharmaceuticals affecting the CNS and 28.0% patients over 60 years of age with chronic oral application of theophylline, digoxin or lithium. The most common errors were improper dose (60.9%), wrong drug (19.3%) or erroneous route of administration (12.9%).
The most frequent errors appeared using antibiotics as well as drugs affecting the central nervous system and the respiratory system. Nurses administering the drugs were responsible for 43.0%, physicians for 36.8% and pharmacists for 20.2% of the errors.
Medication errors represent an important cause of patient morbidity and mortality and have remained in the focus of attention of health care quality experts for more than 10 years after the landmark publication of the American Institute of Medicine appeared. The purpose of the study was to analyse medication errors committed by health care professionals that led to toxicological consultations at the Czech TIC and to identify the categories of special concern needing further interventions of health care quality experts.