Table 3.
Root Causes of Medication Errors and the Resulting Error Types in Two Inpatient Studies
| Leape, 199578 | Lesar, 199731 | |
|---|---|---|
| Error detection method | Chart review plus nurse & pharmacist reporting | Pharmacist interception |
| Root cause | ||
| Lack of knowledge about the drug | 22% | 33% |
| Lack of knowledge about the patient | 14 | 29 |
| Calculation, decimal point, units errors | 18 | |
| Nomenclature errors (slips in drug name, dosage form, or abbreviation) | 13 | |
| Faulty administrative processes | 3 | |
| Rule violations | 10 | |
| Slips and memory lapses | 9 | |
| Transcription errors | 9 | |
| Other* | 34 | |
| Unclassified | 3 | |
| Total | 100% | 100% |
| Error type | ||
| Wrong dosage | 44% | 58% |
| Wrong drug choice, other than allergy | 25 | 22 |
| Known allergy | 12 | 13 |
| Wrong route of administration | 2 | 3 |
| Other† | 17 | 4 |
| Total | 100% | 100% |
*
Includes faulty drug identity checking, faulty dose checking, faulty interaction with other services, infusion pump and parenteral delivery problems, inadequate monitoring, drug stocking and delivery problems, preparation errors, and lack of standardization.
†
Includes orders written for or administered to the wrong patient, errors in timing of administration, failures to monitor drug therapy or to act on monitoring results, and “miscellaneous” errors.