Patient Medication Errors Doubled Over 13 Years

The most common errors were taking or giving the wrong medication or incorrect dosage, and inadvertently taking or giving a medication twice, researchers have found. 

The frequency of serious medication errors by patients or their caregivers outside of a healthcare setting more than doubled from 2000 to 2012, according to a study in Clinical Toxicology.

Researchers from the Center for Injury Research and Policy and the Central Ohio Poison Center at Nationwide Children’s Hospital analyzed calls to poison control centers across the country over the 13-year period about medication errors that resulted in serious medical problems.

The rate of serious medication errors per 100,000 people more than doubled from 1.09 in 2000 to 2.28 in 2012. These errors occurred mostly in the home, affected people of all ages, and were associated with a wide variety of medications.

“Drug manufacturers and pharmacists have a role to play when it comes to reducing medication errors,” said Henry Spiller, a co-author of the study, and director of the Central Ohio Poison Center at Nationwide Children’s. “There is room for improvement in product packaging and labeling. Dosing instructions could be made clearer, especially for patients and caregivers with limited literacy or numeracy.”

The most common errors were taking or giving the wrong medication or incorrect dosage, and inadvertently taking or giving the medication twice. Among children, dosing errors and inadvertently taking or giving someone else’s medication were also common errors. One-third of medication errors resulted in hospital admission.

The medication categories most frequently associated with serious outcomes were cardiovascular drugs (21%), analgesics (12%), and hormones/hormone antagonists (11%). Most analgesic exposures were related to products containing acetaminophen (44%) or opioids (34%), and nearly two-thirds of hormone/hormone antagonist exposures were associated with insulin. Cardiovascular and analgesic medications combined accounted for 66% of all fatalities in this study.

Among children younger than six years, the rate of medication errors increased early in the study and then decreased after 2005, which was associated with a decrease in the use of cough and cold medicines attributable to the Food and Drug Administration’s 2007 warning against giving these drugs to children.

“Managing medications is an important skill for everyone, but parents and caregivers have the additional responsibility of managing others’ medications,” said study lead author Nichole Hodges, a researcher at the Center for Injury Research and Policy at Nationwide Children’s.

“When a child needs medication, one of the best things to do is keep a written log of the day and time each medication is given to ensure the child stays on schedule and does not get extra doses.”

Data for the study were obtained from the National Poison Data System, which is maintained by the American Association of Poison Control Centers.