TY - JOUR
T1 - Types, prevalence, and potential clinical significance of medication administration errors in assisted living
AU - Young, Heather M
AU - Gray, Shelly L.
AU - McCormick, Wayne C.
AU - Sikma, Suzanne K.
AU - Reinhard, Susan
AU - Johnson Trippett, Linda
AU - Christlieb, Carol
AU - Allen, Tiffany
PY - 2008/7
Y1 - 2008/7
N2 - OBJECTIVES: To describe the types and potential clinical significance of medication administration errors in assisted living (AL). DESIGN: Cross-sectional observational study. SETTING: This study was conducted in 12 AL settings in three states (Oregon, Washington, and New Jersey). PARTICIPANTS: Participants included 29 unlicensed assistive personnel and 510 AL residents. MEASUREMENTS: Medication administration observations, chart review, and determination of rates, types, and potential clinical significance of errors using standardized methodology. RESULTS: Of 4,866 observations, 1,373 errors were observed (28.2% error rate). Of these, 70.8% were wrong time, 12.9% wrong dose, 11.1% omitted dose, 3.5% extra dose, 1.5% unauthorized drug, and 0.2% wrong drug. Excluding wrong time, the overall error rate dropped to 8.2%. Of the 1,373 errors, three were rated as having potential clinical significance. CONCLUSION: A high number of daily medications are given in AL. Wrong time accounted for the majority of the errors. The bulk of the medications are low risk and routine; to promote optimal care delivery, clinicians need to focus on high-risk medications and residents with complex health problems.
AB - OBJECTIVES: To describe the types and potential clinical significance of medication administration errors in assisted living (AL). DESIGN: Cross-sectional observational study. SETTING: This study was conducted in 12 AL settings in three states (Oregon, Washington, and New Jersey). PARTICIPANTS: Participants included 29 unlicensed assistive personnel and 510 AL residents. MEASUREMENTS: Medication administration observations, chart review, and determination of rates, types, and potential clinical significance of errors using standardized methodology. RESULTS: Of 4,866 observations, 1,373 errors were observed (28.2% error rate). Of these, 70.8% were wrong time, 12.9% wrong dose, 11.1% omitted dose, 3.5% extra dose, 1.5% unauthorized drug, and 0.2% wrong drug. Excluding wrong time, the overall error rate dropped to 8.2%. Of the 1,373 errors, three were rated as having potential clinical significance. CONCLUSION: A high number of daily medications are given in AL. Wrong time accounted for the majority of the errors. The bulk of the medications are low risk and routine; to promote optimal care delivery, clinicians need to focus on high-risk medications and residents with complex health problems.
KW - Assisted living
KW - Medication administration
KW - Medication errors
KW - Quality
KW - Unlicensed assistive personnel
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U2 - 10.1111/j.1532-5415.2008.01754.x
DO - 10.1111/j.1532-5415.2008.01754.x
M3 - Article
C2 - 18482296
AN - SCOPUS:48449104769
VL - 56
SP - 1199
EP - 1205
JO - Journal of the American Geriatrics Society
JF - Journal of the American Geriatrics Society
SN - 0002-8614
IS - 7
ER -