Assessing Causation in a Medical Malpractice Case
November 5, 2018
Serotonin Syndrome: A Case Review
November 19, 2018

Medication Error Rates

According to ISMP, “A national or other regional medication error rate does not exist. It is not possible to establish a national medication error rate or set a benchmark for medication error rates. Each hospital or organization is different. The rates that are tracked are a measure of the number of reports at a given institution not the actual number of events or the quality of the care given.”

However, our experience has been that more data is better than no data. Comparing medication error rates between comparable institutions may actually be worthwhile. Certainly, in comparing two similar institutions, a large variation in error rates may be of consequence. This should be considered when comparing the overall rate as well as comparing the rates for specific events. For example, we find that in two similar institutions, the medication error rate for once daily gentamicin overdosing is 50% in one hospital and only 10% in the other. This may be worthy of scrutiny. Upon inspection, we might find that the variability might very well suggest that one hospital has a lower rate as a result of having a pharmacokinetics service. To further the point, assume the latter hospital implements a PK service and their rate decreases. Such a scenario affirms our position and the potential value of assessing medication error rates.

In addition, tracking medication error rates can prove beneficial when a hospital assesses its own rates over time. The most obvious example is when anecdotal evidence suggests an issue with a particular event type. If we determine a baseline medication error rate for the event, we can then assess the impact of the corrective action taken to prevent the event from recurring. A decreased medication error rate suggests that the corrective action is working. Alternatively, no change in the rate might suggest that there was a flaw in the root cause analysis which would require reassessment of the event cause.

Thus, our conclusion is that medication error rates are a valuable part of any medication errors program.

Comments are closed.