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Drug administration errors in an institution for individuals with intellectual disability: an observational study. 2007

P M L A van den Bemt, and R Robertz, and A L de Jong, and E N van Roon, and H G M Leufkens
Utrecht Institute for Pharmaceutical Sciences (UIPS), Department of Pharmacoepidemiology & Pharmacotherapy, Utrectht University, Utrecht, and Hospital Pharmacy Midden-Brabant, TweeSteden Hospital, Tilburg, The Netherlands. P.vandenbemt@uu.nl

BACKGROUND Medication errors can result in harm, unless barriers to prevent them are present. Drug administration errors are less likely to be prevented, because they occur in the last stage of the drug distribution process. This is especially the case in non-alert patients, as patients often form the final barrier to prevention of errors. Therefore, a study was set up aimed at identifying the frequency of drug administration errors and determinants for these errors in an institution for individuals with intellectual disability (ID). METHODS This observational study ('disguised observation') was conducted within an institution in the Netherlands caring for 2500 individuals with ID and lasted from October to December 2004 with a case control design for identifying determinants for errors. The institution consists of both day care units and living units (providing full-time care), located in different towns. For the study, five units from different towns were selected. Within each study unit, the administration of drugs to patients was observed for 2 weeks. In total, 953 drug administrations to 46 patients (25 male, mean age 25.8 years, range 2-73 years) were observed. RESULTS With inclusion of wrong time errors, 242 administrations with at least one error were observed [frequency=242/953 (25.4%)] and with exclusion 213 administrations with at least one error were observed [frequency=213/953 (22.4%)]. Determinants associated with errors were routes of administration 'oral by feeding tube' (OR 189.66; 95% CI 46.16-779.24) and 'inhalation' (OR 9.98; 95% CI 4.78-20.80), the units 'adult full-time care' (OR 2.12; 95% CI 1.05-4.35) and 'children daytime care' (OR 10.80; 95% CI 4.43-26.29) and the absence of a distribution robot (OR 4.0; 95% CI 2.67-5.95). None of the identified errors were reported to the voluntary reporting system. CONCLUSIONS This study shows that administration errors in an institution for individuals with ID are common and that they are not formally reported to the voluntary reporting system. Furthermore, it identified some determinants that may be the focus for future improvements aimed to reduce error frequency.

UI MeSH Term Description Entries
D008297 Male Males
D008508 Medication Errors Errors in prescribing, dispensing, or administering medication with the result that the patient fails to receive the correct drug or the indicated proper drug dosage. Drug Use Error,Errors, Medication,High-Alert Drug Error,High-Alert Medication Error,LASA Medication Errors,Look-Alike Drug Name Errors,Look-Alike Sound-Alike Drug Errors,Look-Alike Sound-Alike Drug Substitution Errors,Look-Alike Sound-Alike Medication Errors,Lookalike Drug Name Errors,Lookalike Soundalike Drug Errors,Lookalike Soundalike Drug Substitution Errors,Lookalike Soundalike Medication Errors,Drug Error, High-Alert,Drug Use Errors,Error, Drug Use,Error, LASA Medication,Error, Medication,High Alert Drug Error,High Alert Medication Error,High-Alert Drug Errors,High-Alert Medication Errors,LASA Medication Error,Look Alike Drug Name Errors,Look Alike Sound Alike Drug Errors,Look Alike Sound Alike Drug Substitution Errors,Look Alike Sound Alike Medication Errors,Medication Error,Medication Error, High-Alert,Medication Error, LASA,Medication Errors, High-Alert,Medication Errors, LASA
D008607 Intellectual Disability Subnormal intellectual functioning which originates during the developmental period. This has multiple potential etiologies, including genetic defects and perinatal insults. Intelligence quotient (IQ) scores are commonly used to determine whether an individual has an intellectual disability. IQ scores between 70 and 79 are in the borderline range. Scores below 67 are in the disabled range. (from Joynt, Clinical Neurology, 1992, Ch55, p28) Disability, Intellectual,Idiocy,Mental Retardation,Retardation, Mental,Deficiency, Mental,Intellectual Development Disorder,Mental Deficiency,Mental Retardation, Psychosocial,Deficiencies, Mental,Development Disorder, Intellectual,Development Disorders, Intellectual,Disabilities, Intellectual,Disorder, Intellectual Development,Disorders, Intellectual Development,Intellectual Development Disorders,Intellectual Disabilities,Mental Deficiencies,Mental Retardations, Psychosocial,Psychosocial Mental Retardation,Psychosocial Mental Retardations,Retardation, Psychosocial Mental,Retardations, Psychosocial Mental
D008875 Middle Aged An adult aged 45 - 64 years. Middle Age
D011446 Prospective Studies Observation of a population for a sufficient number of persons over a sufficient number of years to generate incidence or mortality rates subsequent to the selection of the study group. Prospective Study,Studies, Prospective,Study, Prospective
D002648 Child A person 6 to 12 years of age. An individual 2 to 5 years old is CHILD, PRESCHOOL. Children
D002675 Child, Preschool A child between the ages of 2 and 5. Children, Preschool,Preschool Child,Preschool Children
D005260 Female Females
D006801 Humans Members of the species Homo sapiens. Homo sapiens,Man (Taxonomy),Human,Man, Modern,Modern Man
D000293 Adolescent A person 13 to 18 years of age. Adolescence,Youth,Adolescents,Adolescents, Female,Adolescents, Male,Teenagers,Teens,Adolescent, Female,Adolescent, Male,Female Adolescent,Female Adolescents,Male Adolescent,Male Adolescents,Teen,Teenager,Youths

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