Retrospective analysis of mortalities associated with medication errors

The types, causes, contributing factors, and patient demographics of fatal medication errors were reviewed. Case reports of medication errors from hospitals, ambulatory care settings, and patients' homes that were entered in FDA's Adverse Event Reporting Sys tem during 1993-98 were the source of information on fatal medication error s. Each report was classified using predefined criteria and a taxonomy deve loped by the National Coordinating Council for Medication Error Reporting a nd Prevention. The types, causes, contributing factors, and patient demogra phics were identified, and the causality of each case was assessed to preve nt future fatalities. The data indicated 5366 medication error reports. Fifty-nine reports were e xcluded and classified as duplicate reports or intentional overdoses. Of th e remaining medication error reports, 68.2% resulted in serious patient out comes and 9.8% were fatal. Of the 469 fatal medication error reports, 48.6% occurred in patients over 60 years. The most common types of errors result ing in patient death involved administering an improper dose (40.9%), admin istering the wrong drug (16%), and using the wrong route of administration (9.5%). The most common causes of errors were performance and knowledge def icits (44%) and communication errors (15.8%). Fatal medication errors accou nted for approximately 10% of medication errors reported to FDA and were mo st frequently the result of improper dosing of the intended drug and admini stration of an incorrect drug. A review of case reports of medication errors from 1993 to 1998 yielded inf ormation on the most frequent causes of and contributing factors involved i n fatal medication errors.