Analgesic medication errors, including prescribing errors, common but preventable

February 4, 2011

Medication errors involving analgesics, including mistakes in prescribing, are a major contributor to suboptimal therapeutic outcomes and preventable adverse patient events, according to a study published in the Journal of Pain, reported Newswise.com.

Medication errors involving analgesics, including mistakes in prescribing, are a major contributor to suboptimal therapeutic outcomes and preventable adverse patient events, according to a study published in The Journal of Pain, reported Newswise.com.

The frequency of analgesic drug errors in hospitals is nearly 3 per 1,000 prescriptions, based on a study performed in a 631-bed tertiary care facility.

Researchers at Albany (NY) Medical Center examined a large database of pharmacist-detected-and-prevented prescribing errors seeking to quantify and define characteristics and uses associated with increased risk for errors. Previous studies reported that a significant number of analgesic prescribing mistakes are preventable, and errors occur in all steps of the medication-use process with prescribing errors as the major cause, the authors noted.

The overall error rate was 2.87 errors per 1,000 analgesic orders, with a potentially serious prescribing error rate of .63 per 1,000. Error rates were higher in pediatric orders.

“Medication errors are made with medications as common as analgesics leading us to believe that current training in drug education is inadequate and prescribers likely need more training and education in drug therapy,” Ripple Shah, PharmD, a senior scientist, Hartford Hospital and University of Conn., told Formulary.

For the analysis, 714,290 orders for analgesics were reviewed by pharmacists. Analgesics were organized by their drug class and dosage forms, such as anti-inflammatory agents, immediate-release opioids, injectable drugs, transdermal agents, and acetaminophen. Each reported error was evaluated by the contributing cause: failure to modify therapy based on patient-specific information, inadequate drug therapy knowledge, inappropriate use of a dosage form, mistakes in dose calculations, improper dose for the route of administration, and others.

The authors reported a total of 2,044 prescribing errors (.29%) and 22% (449) were considered as potentially serious. Among pediatric cases, there were 243 errors in 40,996 analgesic orders (.59%). Pediatric drug errors accounted for 14% of mistakes rated as potentially serious. Error rates varied widely between individual drugs, and the highest numbers of individual analgesic errors occurred with some infrequently prescribed medications, such as buprenorphine and benzocaine. Also, look-alike and sound-alike drug names comprised a significant proportion of medication errors found.

For risk-reduction improvements, the authors advised that computerized prescriber order entry systems can reduce but not eliminate errors. Other safeguards that should be implemented include limiting the number of similar medications available on the formulary and reviews of drug orders by pharmacists and nurses for every prescribed analgesic.