Primary Source: “Medication Errors in the Outpatient Setting: Classification and Root Cause Analysis.” Friedman AL “Medication Errors in the Outpatient Setting: Classification and Root Cause Analysis.” Arch Surg 2007; 142:278-283.
Additional Source: “Medication Errors in the Outpatient Setting — Invited Critique” Makary MM “Medication Errors in the Outpatient Setting — Invited Critique” Arch Surg 2007; 142: 284.
The Study
93 liver, kidney, or pancreas transplant patients were followed for 12 months, during which 149 medication errors were found.
Among these patients, the average number of prescribed medications was 10.9.
One-third of the errors were severe enough to have an impact on the graft’s survival. Nine graft rejections and six transplant failures were among the results of those errors.
The errors were divided into categories:
- Patient error – 56%1
- Prescription error – 20%
- Delivery error – 13%
- Availability error – 10%2
- Reporting error – 8%3
The sources of error were also designated:
- Patients – 68%
- Pharmacies and other sectors of the health care team – 27%
- Finances – 5%
Commentary
The contrast between the scientific and sophisticated technologies necessary for a successful transplant and creating medications to support the survival of that transplant patient and the systemically flawed methodologies responsible for those medications actually being used correctly by the post-transplant patient is striking and dramatically highlights the importance of improving adherence.
I am less impressed with the classification scheme. Given the that the patient’s use of the right medication at the right time is the final common pathway and the complex communication pathway that conveys healthcare instructions, warnings, and exceptions to the patient, the surprise would have been if “patient error” were not the leading category of error.
