analysis of medication errors of health care providers on the basis of data from the czech...

Analysis of Medication Errors of Health Care Providers on theBasis of Data from the Czech Toxicological Information Centre over

an 11-Year Period (2000–2010)Sergey Zakharov1,2, Tomas Navratil3 and Daniela Pelclova4

1Health Law Centre, Third Faculty of Medicine, Charles University in Prague, Prague, Czech Republic,2Toxicological Information Centre,Department of Occupational Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital, Prague,

Czech Republic, 3Department of Biophysical Chemistry, J. Heyrovsky Institute of Physical Chemistry of AS CR, v.v.i., Prague, Czech Republic,and 4Toxicological Information Centre, Department of Occupational Medicine, First Faculty of Medicine, Charles University in Prague and

General University Hospital, Prague, Czech Republic

(Received 14 July 2011; Accepted 7 November 2011)

Abstract: This study aimed to analyse medication errors committed by health care professionals leading to toxicologicalconsultations at the Czech Toxicological Information Centre and to identify the categories of special concern for furtherinterventions of health care quality experts.

From the Toxicological Information Centre (TIC) database,44,344 calls concerning drug application were studied retro-spectively over the period of 2000–2010. The calls regardingmedication errors caused by mistakes of the health care per-sonnel were identified and analysed.

From 215 calls regarding medication errors, 130 involvedchildren (90 below 5 years of age) and 85 adults (30 over60 years of age). Of 25 patients with severe drug intoxica-tions, 60.0% were children under 5 years of age with paren-teral administration of the pharmaceuticals affecting theCNS and 28.0% patients over 60 years of age with chronicoral application of theophylline, digoxin or lithium. Themost common errors were improper dose (60.9%), wrongdrug (19.3%) or erroneous route of administration (12.9%).The most frequent errors appeared using antibiotics as wellas drugs affecting the central nervous system and the respira-tory system. Nurses administering the drugs were responsiblefor 43.0%, physicians for 36.8% and pharmacists for 20.2%of the errors.

Children under 5 years of age treated with parenteraladministration of the pharmaceuticals affecting the centralnervous system, in which the dose was not correctlyadjusted, and elderly people with chronic oral medication oftheophylline, digoxin, lithium and insufficient control of themedication level were exposed to a higher risk of serioushealth problems and death because of medication errors.

Medication errors represent an important cause of patientmorbidity and mortality and have remained in the focus ofattention of health care quality experts for more than

10 years after the landmark publication of the AmericanInstitute of Medicine appeared [1–6]. More than 1 millionserious medication errors occur every year in US hospitals[7]. The rate of medication errors varies between 2% and14% of patients admitted to hospital [8–14]. Approximately,20% of medication errors are serious and life-threatening[15–17]. There is a higher risk of serious health effects ofmedication errors in children [18–23]. On the other hand,inadequate medication is considered as one of the leadingrisk factors of drug-morbidity among people over the age of65 years [24–29].

Unlike adverse drug reactions or adverse drug events,medication errors are always caused by a mistake of thehealth care personnel [30,31]. Medical doctors then seekrapid and qualified advice in a toxicological informationcentre ⁄ poison control centre to avert a risk of severe conse-quences of inadvertent drug overdose or wrong pharmaceuticaluse and to efficiently treat the patient. The electronic datacollected by toxicological information centres via telephonecalls from health care professionals inquiring a toxicologicalconsultation are considered one of the relevant sources ofinformation about the occurrence of medical malpracticesrelated to the inappropriate use of medications in the processof providing health care [32–35].

The purpose of the study was to analyse medication errorscommitted by health care professionals that led to toxicologi-cal consultations at the Czech TIC and to identify the cate-gories of special concern needing further interventions ofhealth care quality experts.

Materials and Methods

Toxicological Information Centre in Prague is the only unit of thiskind in the country with a population of 10 million. It provides24-hr telephone consultations for both health care professionals and

Author for correspondence: Sergey Zakharov, Toxicological Informa-tion Centre, Department of Occupational Medicine, First Faculty ofMedicine, Charles University in Prague and General UniversityHospital, Na BojiÐti 1, 120 00 Prague 2, Czech Republic (fax+420 224 964 325, e-mail [email protected]).

Basic & Clinical Pharmacology & Toxicology, 2012, 110, 427–432 Doi: 10.1111/j.1742-7843.2011.00830.x

� 2011 The AuthorsBasic & Clinical Pharmacology & Toxicology � 2011 Nordic Pharmacological Society

lay persons concerning toxicity of a wide range of substances (chemi-cals, consumer goods, medicines, etc.), on diagnostics and treatmentof acute poisonings. During each phone consultation, the specialistsof TIC fill in a standardized electronic questionnaire containing thedefinite list of variables and give a full text description of the eventscenario. The variables present in the database include: patient's andmedical facilities identification data, telephone number of the caller,type of event, characteristics of toxic agent, time, dose and route ofintoxication, symptoms and severity of the health condition, mea-sures already performed and treatment recommended. In the casesconcerning the misapplication of drugs, the situation that led to theoverdose (or administration of the pharmaceutical in an inappropri-ate way, or of the wrong drug) is described in detail. Every phonecall is registered in the database, and the data are daily controlled bythe head of TIC. All calls are documented, as the time and phonenumber appears automatically on the phone.

The information on follow-up regarding the consequences of med-ication errors reported is received from the copies of medical dis-charge records, additionally sent to TIC on the request by themedical facilities. The quality of case report data extraction is con-trolled by the head of TIC, and the hospital is contacted for furtherdata if needed.

Forty-four thousand three hundred forty-four calls to TIC con-cerning the application of drugs were studied retrospectively fromthe electronic database over the period of 2000–2010. Only callsregarding medication errors caused by mistakes of the health carepersonnel were selected for further analysis. The data collected werecategorized into health care facility type, patient age group, medicalstaff involved, pharmaceutical administered, error type and severityof symptoms. Health care facility type included inpatient depart-ments of hospitals, outpatient medical facilities and pharmacies.Medical staff involved physicians, nurses and pharmacists. Agegroups were: babies (0–1 year), children 1–5 years, children over5 years (5–18 years), adults under 45 years, adults over 45 years andsenior adults (older than 60 years). The drugs administered wereclassified according to the Anatomical Therapeutic Chemical (ATC)classification [36]. Error type involved dosing, route of administra-tion, administration or dispensing of the wrong medication and tothe wrong patient. Estimations of doses of drugs were: non-toxic,minor toxic, moderate toxic, severe toxic, severity unknown andunknown dose. Severity of symptoms of intoxication was classifiedaccording to the Poisoning Severity Score [37].

Results

Toxicological Information Centre received 215 calls fromhealth care professionals because of medication errors from2000 to 2010 representing 0.5% of all calls concerning drugs.In total, 61.9% of calls concerned medication errors in theinpatient departments of hospitals, 18.6% in the outpatientmedical facilities and 19.5% in the pharmacies.

From the calls analysed, 130 involved children and 85 con-cerned adults. Among all patients with medication errorscommitted during treatment, children constituted 60.4%,and 43.7% of these were under 5 years old. Among adults,41.2% of the patients were older than 60 years (fig. 1).

The involvement of drug classes according to the ATC clas-sification in medication errors is shown in table 1. The mostfrequent medication errors occurred using drugs affecting thecentral nervous system, especially psycholeptics (haloperidol,promethazine, lithium, etc.) and antiepileptics (valproates,phenytoin, lamotrigine, etc.). The second place was occupiedby antibiotics and the third by drugs affecting the respiratorysystem, where the acute and chronic overdoses of theophyl-line preparations constituted the major part.

The estimation of administered doses indicated that over-doses occurred in 63.4% of calls, including 7.4% with dosesclassified as severely toxic (fig. 2). In 44.2% of inquiries, thehealth care professionals called TIC before the onset of firstsigns and symptoms of intoxication. The evaluation of symp-toms, occurring at the time of the call, is presented in fig. 3.

Severe drug intoxications were 25 (11.6%) with 7 (3.3%)being lethal. Children under 5 years of age were involved in15 (60.0%) serious cases after acute parenteral overdose withpharmaceuticals affecting the central nervous system, inwhich the dose was not correctly adjusted. Senior adults wereinvolved in seven (28.0%) cases of severe drug intoxicationbecause of chronic oral administration of theophylline,digoxin or lithium. Forced diuresis (five patients), extracor-poral elimination method (19 patients) or specific antidotes(four patients) were recommended in 28 (13.0%) calls.

The following case reports illustrate the severe intoxica-tions in children and elderly adults:

• Eight-day-old newborn with neonatal seizures hadreceived phenobarbital injections i.v. repeatedly and devel-oped coma. Phenobarbital blood level was in the lethalrange. Haemoperfusion was performed, however, the new-born died.

• Three-month-old baby had received a single i.v. injectionof phenobarbital; the dose was four times higher than themaximum therapeutic dose. The child had been unconsciousduring the inquiry. Haemoperfusion was performed and thechild survived.

• Four-month-old baby was given one dose of neostigmineinjection i.v.; the dose was ten times higher than the maxi-mum therapeutic dose because of inappropriate dilution.The child died from cardiac arrest.

• Seventy-year-old female outpatient treated with theoph-ylline orally and without blood level controls for severalmonths had been admitted to hospital because of seizuresand tachycardia, and lethal serum theophylline concentrationwas measured; haemoperfusion was carried out and thepatient survived.

• Seventy-six-year-old male with chronic kidney failurehospitalized at the internal department had been treated withdigoxin without proper dosage adjustment, so he developedsevere bradycardia, hyperkalaemia and acidosis. Therefore,haemoperfusion was performed and the patient survived.

0

10

20

30

40

50

60

0 – 1 year 1 – 5 years 5 –18 years 18 – 45 years

45 – 60 years

Older than 60 years

17.7 %

26.0 %

16.7 %

12.6 % 10.7 %

16.3 %

No.

of m

edic

aon

err

ors

Age

Fig. 1. Age of patients affected by medication errors registered bythe Czech Toxicological Information Centre from 2000 to 2010.

428 SERGEY ZAKHAROV ET AL.


The quantitative analysis of the types of medication errorsindicated that the most common ones were improper doseadministration, wrong drug administration, improper routeof administration and administration to a wrong patient. Insome of the cases analysed, there were several different errorsoccurring at the same time.

The medical staff categories involved in medication errorsare presented in the table 2. Among medication errors com-mitted by nurses, the most frequent one was wrong doseadministration (39.6%), and one-time overdoses (32.3%) pre-vailed against repeated doses (7.3%). A significant partof nurse errors (30.2%) consisted of cases of wrong drug

Table 1.Drug classes according to the Anatomical Therapeutic Chemical (ATC) classification involved in medication errors in the calls to the CzechToxicological Information Centre in 2000–2010.

Drug class (ATC classification)Total number

of callsNumberof calls

Totalpercentage

of the calls (%)Percentage

of the calls (%)

N (Nervous system) 54 25.1N01 (anaesthetics) 4 1.9N02 (analgesics) 9 4.2N03 (antiepileptics) 18 8.3N05 (psycholeptics) 21 9.8N06 (psychoanaleptics) 2 0.9

J (Anti-infectives for systemic use) 33 15.3J01 (Antibacterials for systemic use) 33 15.3

R (Respiratory system) 29 13.5R03 (drugs for obstructive airway diseases) 15 7.0R05 (expectorants, mucolytics, cough suppressants) 10 4.6R06 (antihistamines for systemic use) 4 1.9A (Alimentary tract and metabolism): 24 11.2A02 (drugs for acid-related disorders) 1 0.5A03 (drugs for functional gastrointestinal disorders) 1 0.5A04 (antiemetics and antinauseants) 13 6.1A07 (antidiarrhoeals, intestinal anti-infective agents) 2 0.9A10 (drugs used in diabetes) 2 0.9A11 (vitamins) 3 1.4A12 (mineral supplements) 2 0.9

D (Dermatologicals) 21 9.8D06 (antibiotics and chemotherapeutics for dermatological use)

4 1.9

D08 (antiseptics and disinfectants) 15 7.0D11 (other dermatological preparations) 2 0.9

C (Cardiovascular system) 10 4.7C01 (cardiac therapy) 5 2.3C03 (diuretics) 1 0.5C04 (peripheral vasodilators) 2 0.9C07 (beta blocking agents) 1 0.5C08 (calcium channel blockers) 1 0.5

L (Antineoplastic and immunomodulating agents) 10 4.7L01 (antineoplastic agents) 7 3.3L03 (immunostimulants) 1 0.5L04 (immunosuppressants) 2 0.9

M (Musculo-skeletal system) 4 1.9M02 (anti-inflammatory and antirheumatic products) 3 1.4M04 (antigout preparations) 1 0.5

B (Blood and blood forming organs) 4 1.9B02 (antihaemorrhagics) 1 0.5B03 (antianaemic preparations) 3 1.4

G (Genito-urinary system): 2 0.9G03 (sex hormones and modulators of the genital system) 2 0.9

H (Systemic hormonal preparations) 2 0.8H02 (corticosteroids for systemic use) 2 0.8

S (Sensory organs): S01 (ophthalmologicals) 2 2 0.9 0.9V (Various) 11 11 5.1 5.1P (Antiparasitic products) 1 1 0.5 0.5Combination of different drugs 8 8 3.7 3.7Total 215 100.0

ANALYSIS OF MEDICATION ERRORS OF HEALTH CARE PROVIDERS 429


administration, that is, unintentional substitution of the pre-scribed preparation for another one. Errors associated withimproper route of administration, such as intravenous

administration of intramuscular preparation (depot forms),occupied the third place in the category of nurse errors(21.9%).

A further breakdown of medication errors committed byphysicians indicated that the main part again was related todrug overdose (73.2%), either single (39.0%) or repeated(34.2%). The proportion of improper dose administrationwas almost two times higher than in nurse medication errors.The second place was occupied by cases of wrong drugadministration (17.1%), followed by wrong route of adminis-tration cases (9.7%).

A review of medication errors committed by pharmacistsindicated that 84.4% of these were associated with providingthe patient with drugs in a higher dosage than had been pre-scribed, and 15.6% concerned dispensing of wrong drugs(substitution of prescribed medications).

Discussion

The analysis and interpretation of data obtained are charac-terized by several limitations. Primarily, physicians consultTIC on a voluntary basis, and the number of errors registereddoes not reflect the actual quantity. Generally, <5% of thetotal medication incidents are reported [38,39]. Therefore,most medication errors remain out of sight of TIC specialists.

According to the data obtained, 60.0% of cases of severedrug intoxication involved children under 5 years of age. Inthese patients, intravenous phenobarbital overdosesaccounted for 4 severe acute poisonings including 2 withlethal outcome; in addition, one child’s death was registeredafter intravenous administration of neostigmine. The other10 cases of serious intoxications of children were caused byparenteral overdoses of pharmaceuticals affecting the centralnervous system (valproates, midazolame and ketamine).Generally, injectable medications are of particular concernbecause of the high likelihood of harm [40]. According toHatcher et al., 54.0% of potential ADE and 61.0% of seri-ous and life-threatening errors are associated with intrave-nous medications [41]. The study supports the previousfinding that paediatric patients are generally exposed to ahigher risk of potentially dangerous medication errors thanadults [42].

Elderly adults, on the other hand, were more likely todevelop symptoms of serious intoxication after chronic oraladministration of drugs with cumulative toxicity, like theoph-ylline, digoxin and lithium, because of insufficient monitor-ing of medication (control of laboratory values) by aphysician.

For all three categories of health care professionals, impro-per dose was the most frequent error type. Nursing was thenumber one category of medical disciplines involved in themedication errors. One of the probable reasons for this factis that nurses spend up to 40% of their working hoursadministering medications [43]. Drug administration isreferred to as the ‘sharp edge’ in the medication-use process,because a great deal of preventable medication errors occurat the ‘error-prone’ administration step [44].

Severe toxic7.4%

Severity unknown25.1%

Moderate toxic9.3%

Minor toxic21.4%

Non-toxic25.6%

Unknown dose11.2%

Fig. 2. Estimation of drug doses administered to patients because ofmedication errors registered by the Czech Toxicological InformationCentre from 2000 to 2010.

No symptoms44.2%

Minor symptoms33.5%

Moderatesymptoms

8.4%

Severe symptoms7.0%

Symptoms unrelated to the

intoxica on3.3%

Unknown symptoms

(not reported)3.7%

Fig. 3. Symptoms of drug intoxication at the time of toxicologicalconsultation provided because of medication errors registered by theCzech Toxicological Information Centre from 2000 to 2010.

Table 2.Types of medication errors and medical staff involved according tothe calls of health care workers to the Czech ToxicologicalInformation Centre from 2000 to 2010.

Characteristics of medication errors

Number of errors(Percentage of

the calls %)

Total Subtotal

Nurse errors 96 (43.0)Drug overdose 38 (17.0)Wrong drug administration 29 (13.0)Wrong route of administration 21 (9.4)Administration to a wrong patient 8 (3.6)

Physician errors 82 (36.8)Drug overdose 60 (26.9)Wrong drug administration 14 (6.3)Wrong route of administration 8 (3.6)

Pharmacist errors 45 (20.2)Improper (higher) dosage 38 (17.0)Wrong drug dispensation 7 (3.2)

Total 223 (100.0)



Conclusion

Children under 5 years of age treated with parenteral admin-istration of pharmaceuticals affecting the central nervoussystem, in which the dose was not correctly adjusted, wereexposed to a higher risk of serious health problems anddeath because of medication errors. Thus, special attentionand precautions are appropriate when administering pheno-barbital, neostigmine, ketamine and midazolam in neonataland paediatric practice.

For patients over 60 years of age, the implementation ofadditional measures aimed at diminishing health risks associ-ated with chronic oral application of theophylline, digoxinand lithium is also pertinent.

AcknowledgementsThe authors would like to thank for the support by the

GA AV CR (project No. IAA400400806), GA CR (projectNo. P206 ⁄ 11 ⁄ 1638) and MSM 0021620807, and Dr. AngeloFranclin, PhD, for linguistic assistance.

Conflict of InterestThe authors report no conflict of interest. The authors

alone are responsible for the content and writing of thispaper.

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