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Types, Prevalence, and Potential Clinical Significance of Medication Administration Errors in Assisted Living
Author(s) -
Young Heather M.,
Gray Shelly L.,
McCormick Wayne C.,
Sikma Suzanne K.,
Reinhard Susan,
Johnson Trippett Linda,
Christlieb Carol,
Allen Tiffany
Publication year - 2008
Publication title -
journal of the american geriatrics society
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.992
H-Index - 232
eISSN - 1532-5415
pISSN - 0002-8614
DOI - 10.1111/j.1532-5415.2008.01754.x
Subject(s) - medicine , observational study , clinical significance , statistical significance , health care , chart , emergency medicine , statistics , mathematics , economics , economic growth
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.