Order no harm: evidence-based methods to reduce prescribing errors for the clinical nurse specialist.

The Institute of Medicine reports that between 48,000 and 98,000 persons die each year because of medical errors. Medical errors are the eighth leading cause of death, which exceeds the death rate for motor vehicle accidents, breast cancer, and acquired immunodeficiency syndrome. A large teaching hospital can expect to pay more than $5 million a year for errors, and the preventable costs for the United States economy are estimated from $17 to $29 billion each year. Evidence from a study funded by the Agency for Healthcare Research and Quality (AHRQ) found preventable adverse drug events responsible for 1 out of every 5 injuries or death to patients per year. Medication errors include prescribing 2 or more drugs whose interactions are known to produce side effects, prescribing a drug to a patient known to be allergic to that drug, and prescribing the wrong dose. Similar results were found in 2000. A panel of 11 multidisciplinary professionals analyzed medication errors that occurred over 24 months submitted by 249 hospitals to the New York Patient Occurrence Reporting and Tracking System, a mandatory adverse event report system of the New York State Department of Health. In 108 reports, 18% of persons experienced permanent harm. Near-death events accounted for 48% of the reports, and 23% of medication errors resulted in death. Written prescriptions accounted for 74% of the errors, and verbal orders accounted for 15%. Physicians were involved in 58% of the cases, and nurses were involved in 77% of the events. Registered pharmacists were involved in 18% of the cases. The most common medication errors were prescribing the wrong dose or wrong drug. Medication class was also associated with increased risk of error. Cardiovascular agents and narcotics each accounted for 14% of the reports, and errors involving central nervous system drugs and antibiotics each accounted for 8%. Finally, age greater than 65 years was a significant factor associated with medication errors. Transition of the patient across levels of care seems to be the greatest threat contributing to errors. Medications with complex dosing regimens and specialty areas such as intensive care units, emergency departments, and diagnostic and interventional areas also are associated with increased risk of serious medication errors. Additional threats include incomplete patient medication history, lack of redundant safety checks, incomplete bridge therapy when converting from shortto long-term anticoagulation regimens, lack of evidence-based protocols, and staff assuming roles for which they are not prepared. In addition, hospitals without a 24-hour pharmacy are at high risk, particularly when there is an absence of procedural barriers to offset the risk of accessing highrisk drugs. Evidence from studies in the United Kingdom has found similar results as well as other contributing factors for medication errors. Workload, whether or not the prescriber is ordering for his or her own patient or for another provider, and knowledge about the drug prescribed are significantly associated with errors. Furthermore, error risk seems greater during the inpatient stay compared with admission or discharge. Finally, the attitude of the prescriber is significant, particularly if there is a low perceived importance of prescribing compared with other responsibilities.