Medication error trends for 1999-2003

February 21, 2005

Each year, beginning with 1999, United States Pharmacopeia (USP) has conducted an analysis of aggregate data submitted to the MEDMARX error reporting system database. The most recent report examines error trends over the five-year period 1999-2003. It also includes a special focus on technology-related errors, specifically computer entry, computerized prescriber order entry, and automated dispensing devices.

Each year, beginning with 1999, United States Pharmacopeia (USP) has conducted an analysis of aggregate data submitted to the MEDMARX error reporting system database. The most recent report examines error trends over the five-year period 1999-2003. It also includes a special focus on technology-related errors, specifically computer entry, computerized prescriber order entry, and automated dispensing devices.

The number of records submitted to the MEDMARX database in 2003 totaled 235,159, far exceeding the number submitted in any prior year. The increase was due, in part, to an 18% increase in participating MEDMARX facilities that rose from 482 in 2002 to 570 in 2003. The majority of subscribing facilities were nonprofit hospitals and related health systems.

Level of harm In 2003, the majority of reported medication errors did not result in patient harm; only 1.51% resulted in some level of harm. Favorable trends were seen when data over the five-year period 1999-2003 were examined. The percentage of reported medication errors intercepted before reaching the patient steadily increased from 23% (1999) to 38% (2003). A decrease occurred in the percentage of reported medication errors reaching the patient, from 55% in 1999 to 45% in 2003. The 2003 harm threshold of 1.51% is nearly half the five-year peak of 3% that occurred in 2000.

Products The number of unique product groups identified in 2003 was 1,559-an increase over the 1,400 reported in the previous year. Insulin products were most often cited in errors overall and errors that resulted in harm. An examination of the products involved in fatal errors (n=24) revealed that five drugs (enoxaparin, heparin, morphine, nitroglycerin, and warfarin) were on this same list one year ago.

The information in the MEDMARX 5th Anniversary Data Report contains many more findings and is aimed at researchers, clinicians, policy makers, and other patient safety stakeholders with the goal of providing tangible evidence that will drive change. USP is committed to providing meaningful information that contributes further to the growing knowledge base surrounding medication error reporting and prevention and to the safe use of medicines. The complete report can be obtained at http://www.usp.org/. Click on the "USP Store" tab.

USP operates two complementary reporting programs: the Medication Error Reporting Program, presented in cooperation with the Institute for Safe Medication Practices, and MEDMARX. For more information on how to report errors, visit: http://www.usp.org/patientsafety/.