Study: Medication errors often occur at admission

Medication errors are common at the time of hospital admission, and some have the potential to be harmful, according to a recent report in the Archives of Internal Medicine (2005; 165:424-429).

A medication use history is an integral part of the hospital admission process, but errors in the history may result in failure to detect drug-related problems or lead to interrupted or inappropriate drug therapy during hospitalization, according to background information in the article. Earlier studies suggest that these errors are a potentially serious safety issue. The current study was designed to identify unintended discrepancies between physicians’ admission medication orders and a comprehensive medication use history and the potential clinical significance of the discrepancy.

Patricia L. Cornish, BScPhm, a researcher at the University of Toronto, and colleagues screened medical charts from three months of admissions to the general internal medical clinics at an affiliated hospital and included patients in the study if they reported use of at least four medications and were either able to communicate or had a caregiver who could communicate for them. One hundred and fifty-one patients were included in the study.

Eighty-one patients (53.6%) had at least one unintended discrepancy. "We identified 140 unintended discrepancies among these 81 patients," the authors wrote. "The most common error (46.4%) was omission of a regularly used medication. Most (61.4%) of the discrepancies were judged to have no potential to cause serious harm. However, 38.6% of the discrepancies had the potential to cause moderate to severe discomfort or clinical deterioration."

Cornish concludes that the processes for recording medication histories on admission to the hospital are "inadequate, potentially dangerous, and in need of improvement."