Medication errors observed in 36 health care facilities.

Background: Medication errors are a national concern.

Objective: To identify the prevalence of medication errors (doses administered differently than ordered).

Design: A prospective cohort study.

Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities.

The validity and cost-effectiveness of three methods for detecting medication errors were examined. A stratified random sample of 36 hospitals and skilled-nursing facilities in Colorado and Georgia was selected. Medication administration errors were detected by registered nurses (R.

Consultant evaluation of a hospital medication system: implementation and evaluation of the new system.

The effects of consultant-recommended modifications in a hospital medication system on medication-error rates and response times were evaluated. Fourteen recommendations for improving the medication system in a large teaching hospital were implemented to varying extents over a period of 1.5 years.

Consultant evaluation of a hospital medication system: synthesis of a new system.

Recommendations of consultants for the implementation of a new medication system at a large teaching hospital are described. Based on a previous analysis of the hospital's existing drug distribution and control system that revealed problems in reliability and response time, an interdisciplinary consultant group offered 14 recommendations, which included implementation of a computerized unit dose delivery system and selected clinical pharmacy services. Functions identified for which computerization would produce the greatest benefits included maintenance of patient census data, medication order entry and retrieval, and preparation of a medication administration record for nursing.

Consultant evaluation of a hospital medication system: analysis of the existing system.

A consultant team's evaluation of a system for distributing and controlling medications in a large teaching hospital is described. Through interviews with key personnel from administration, pharmacy, nursing, and the medical staff, an interdisciplinary research group identified problems in the reliability and response times of the hospital's existing medication system. After assessing staff expectations regarding acceptable standards for medication errors and response times and their attitudes toward proposed changes in the medication system, medication-error rates were determined using a pharmacist-observer method.