Pharmacy World & Science

, Volume 30, Issue 6, pp 907–915 | Cite as

Prioritising the prevention of medication handling errors

  • Thilo Bertsche
  • Dorothee Niemann
  • Yvonne Mayer
  • Katrin Ingram
  • Torsten Hoppe-Tichy
  • Walter E. HaefeliEmail author
Research Article


Objective Medication errors are frequent in a hospital setting and often caused by inappropriate drug handling. Systematic strategies for their prevention however are still lacking. We developed and applied a classification model to categorise medication handling errors and defined the urgency of correction on the basis of these findings. Setting Nurses on medical wards (including intensive and intermediate care units) of a 1,680-bed teaching hospital. Method In a prospective observational study we evaluated the prevalence of 20 predefined medication handling errors on the ward. In a concurrent questionnaire survey, we assessed the knowledge of the nurses on medication handling. The severity of errors observed in individual areas was scored considering prevalence, potential risk of an error, and the involved drug. These scores and the prevalence of corresponding knowledge deficits were used to define the urgency of preventive strategies according to a four-field decision matrix. Main outcome measure Prevalence and potential risk of medication handling errors, corresponding knowledge deficits in nurses committing the errors, and priority of quality improvement. Results In 1,376 observed processes 833 medication handling errors were detected. Errors concerning preparation (mean 0.88 errors per observed process [95% CI: 0.81–0.96], N = 645) were more frequent than administration errors (0.36 [0.32–0.41], N = 701, P < 0.001). Parenteral drugs (1.10 [1.00–1.19], N = 492) were more often involved in errors than enteral drugs (0.32 [0.28–0.36], N = 794, P < 0.001). Of the 833 observed medication errors 30.9% concerned processes of high risk, 19.0% of moderate risk, and 50.1% of low risk. Of these errors 11.4% were caused by critical dose drugs, 81.6% by uncomplicated drugs, and 6.9% by nutritional supplements or diluents without active ingredient. According to the decision matrix that also considered knowledge deficits two error types concerning enteral drugs (flaws in light protection and prescribing information) were given maximum priority for quality improvement. For parenteral drugs five errors (incompatibilities, flaws in hygiene, duration of administration, check for visible abnormalities, and again prescribing information) appeared most important. Conclusion We successfully applied a newly developed classification model to prioritise medication handling errors for prevention strategies.


Clinical competence Decision making Error detection Germany Knowledge Medication errors Prioritising Questionnaires Risk management Students, pharmacy 



We would like to thank all participating nurses for the successful collaboration.


This work was funded by the University of Heidelberg and supported in part by a grant from the Chamber of Pharmacists Baden-Württemberg, Germany.

Conflicts of interest

The authors have no conflicts of interest to declare.


  1. 1.
    Chan M, Nicklason F, Vial JH. Adverse drug events as a cause of hospital admission in the elderly. Intern Med J. 2001;31:199–205. doi: 10.1046/j.1445-5994.2001.00044.x.PubMedCrossRefGoogle Scholar
  2. 2.
    Taxis K, Barber N. Ethnographic study of incidence and severity of intravenous drug errors. BMJ. 2003;326:684–8. doi: 10.1136/bmj.326.7391.684.PubMedCrossRefGoogle Scholar
  3. 3.
    Taxis K, Barber N. Incidence and severity of intravenous drug errors in a German hospital. Eur J Clin Pharmacol. 2004;59:815–7. doi: 10.1007/s00228-003-0689-9.PubMedCrossRefGoogle Scholar
  4. 4.
    Bates DW, Leape LL, Cullen DJ, Laird N, Petersen LA, Teich JM, et al. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA. 1998;280:1311–6. doi: 10.1001/jama.280.15.1311.PubMedCrossRefGoogle Scholar
  5. 5.
    Bates DW, Teich JM, Lee J, Seger D, Kuperman GJ, Ma’Luf N, et al. The impact of computerized physician order entry on medication error prevention. J Am Med Inform Assoc. 1999;6:313–21.PubMedGoogle Scholar
  6. 6.
    Leape LL, Bates DW, Cullen DJ, Cooper J, Demonaco HJ, Gallivan T, et al. Systems analysis of adverse drug events. ADE Prevention Study Group. JAMA. 1995;274:35–43. doi: 10.1001/jama.274.1.35.PubMedCrossRefGoogle Scholar
  7. 7.
    Kozer E, Seto W, Verjee Z, Parshuram C, Khattak S, Koren G, et al. Prospective observational study on the incidence of medication errors during simulated resuscitation in a paediatric emergency department. BMJ. 2004;329:1321–5. doi: 10.1136/bmj.38244.607083.55.PubMedCrossRefGoogle Scholar
  8. 8.
    Classen DC, Pestotnik SL, Evans RS, Lloyd JF, Burke JP. Adverse drug events in hospitalized patients. Excess length of stay, extra costs, and attributable mortality. JAMA. 1997;277:301–6. doi: 10.1001/jama.277.4.301.PubMedCrossRefGoogle Scholar
  9. 9.
    Bates DW, Spell N, Cullen DJ, Burdick E, Laird N, Petersen LA, et al. The costs of adverse drug events in hospitalized patients. Adverse Drug Events Prevention Study Group. JAMA. 1997;277:307–11. doi: 10.1001/jama.277.4.307.PubMedCrossRefGoogle Scholar
  10. 10.
    Bates DW, Cullen DJ, Laird N, Petersen LA, Small SD, Servi D, et al. Incidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE Prevention Study Group. JAMA. 1995;274:29–34. doi: 10.1001/jama.274.1.29.PubMedCrossRefGoogle Scholar
  11. 11.
    Ferner RE, Aronson JK. Medication errors, worse than a crime. Lancet. 2000;355:947–8. doi: 10.1016/S0140-6736(00)99025-1.PubMedCrossRefGoogle Scholar
  12. 12.
    Ferner RE, Aronson JK. Clarification of terminology in medication errors: definitions and classification. Drug Saf. 2006;29:1011–22. doi: 10.2165/00002018-200629110-00001.PubMedCrossRefGoogle Scholar
  13. 13.
    George J, Munro K, McCaig D, Stewart D. Risk factors for medication misadventure among residents in sheltered housing complexes. Br J Clin Pharmacol. 2007;63:171–6. doi: 10.1111/j.1365-2125.2006.02799.x.PubMedCrossRefGoogle Scholar
  14. 14.
    Dean BS, Barber ND. A validated, reliable method of scoring the severity of medication errors. Am J Health Syst Pharm. 1999;56:57–62.PubMedGoogle Scholar
  15. 15.
    Dean B, Barber N. Validity and reliability of observational methods for studying medication administration errors. Am J Health Syst Pharm. 2001;58:54–9.PubMedGoogle Scholar
  16. 16.
    Taxis K, Dean B, Barber N. The validation of an existing method of scoring the severity of medication administration errors for use in Germany. Pharm World Sci. 2002;24:236–9. doi: 10.1023/A:1021521014172.PubMedCrossRefGoogle Scholar
  17. 17.
    Wong DT, Crofts SL, Gomez M, McGuire GP, Byrick RJ. Evaluation of predictive ability of APACHE II system and hospital outcome in Canadian intensive care unit patients. Crit Care Med. 1995;23:1177–83. doi: 10.1097/00003246-199507000-00005.PubMedCrossRefGoogle Scholar
  18. 18.
    Kim YM, Yoo SH, Kang RY, Kim MJ, Bae YY, Lee YK, et al. Identifying drugs needing pharmacogenetic monitoring in a Korean hospital. Am J Health Syst Pharm. 2007;64:166–75. doi: 10.2146/ajhp050490.PubMedCrossRefGoogle Scholar
  19. 19.
    Health Canada. Guidance for industry bioequivalence requirements: critical dose drugs. Available from Accessed 22 April 2008.
  20. 20.
    Mays N, Pope C. Qualitative research: observational methods in health care settings. BMJ. 1995;311:182–4.PubMedGoogle Scholar
  21. 21.
    Bates DW. Preventing medication errors: a summary. Am J Health Syst Pharm. 2007;64(Suppl 9):S3–9. doi: 10.2146/ajhp070190.PubMedCrossRefGoogle Scholar
  22. 22.
    Lazarou J, Pomeranz BH, Corey PN. Incidence of adverse drug reactions in hospitalized patients: a meta-analysis of prospective studies. JAMA. 1998;279:1200–5. doi: 10.1001/jama.279.15.1200.PubMedCrossRefGoogle Scholar
  23. 23.
    Krahenbuhl-Melcher A, Schlienger R, Lampert M, Haschke M, Drewe J, Krahenbuhl S. Drug-related problems in hospitals: a review of the recent literature. Drug Saf. 2007;30:379–407. doi: 10.2165/00002018-200730050-00003.PubMedCrossRefGoogle Scholar
  24. 24.
    Schneider MP, Cotting J, Pannatier A. Evaluation of nurses’ errors associated in the preparation and administration of medication in a pediatric intensive care unit. Pharm World Sci. 1998;20:178–82. doi: 10.1023/A:1012087727393.PubMedCrossRefGoogle Scholar
  25. 25.
    Vogel Kahmann I, Bürki R, Denzler U, Höfler A, Schmid B, Splisgardt H. Incompatibility reactions in the intensive care unit. Five years after the implementation of a simple “colour code system”. Anaesthesist. 2003;52:409–12. doi: 10.1007/s00101-003-0481-3.PubMedCrossRefGoogle Scholar
  26. 26.
    Cohen B, Saiman L, Cimiotti J, Larson E. Factors associated with hand hygiene practices in two neonatal intensive care units. Pediatr Infect Dis J. 2003;22:494–9. doi: 10.1097/00006454-200306000-00003.PubMedCrossRefGoogle Scholar
  27. 27.
    Tissot E, Cornette C, Limat S, Mourand JL, Becker M, Etievent JP, et al. Observational study of potential risk factors of medication administration errors. Pharm World Sci. 2003;25:264–8. doi: 10.1023/B:PHAR.0000006519.44483.a0.PubMedCrossRefGoogle Scholar
  28. 28.
    Bates DW, Teich JM, Lee J, Seger D, Kuperman GJ, Ma’Luf N, et al. The impact of computerized physician order entry on medication error prevention. J Am Med Inform Assoc. 1999;6:313–21.PubMedGoogle Scholar
  29. 29.
    Fontan JE, Maneglier V, Nguyen VX, Loirat C, Brion F. Medication errors in hospitals: computerized unit dose drug dispensing system versus ward stock distribution system. Pharm World Sci. 2003;25:112–7. doi: 10.1023/A:1024053514359.PubMedCrossRefGoogle Scholar
  30. 30.
    Anderson S, Wittwer W. Using bar-code point-of-care technology for patient safety. J Healthc Qual. 2004;26:5–11.PubMedGoogle Scholar
  31. 31.
    Martin F, Legat C, Coutet J, Bracco-Nolin CH, Jacquet M, Woronoff-Lemsi MC, et al. Prevention of preparation errors of cytotoxic drugs in centralized units: from epidemiology to quality assurance. Bull Cancer. 2004;91:972–6.PubMedGoogle Scholar
  32. 32.
    Leape LL, Cullen DJ, Clapp MD, Burdick E, Demonaco HJ, Erickson JI, et al. Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. JAMA. 1999;282:267–70. doi: 10.1001/jama.282.3.267.PubMedCrossRefGoogle Scholar
  33. 33.
    Bates DW, Leape LL, Cullen DJ, Laird N, Petersen LA, Teich JM, et al. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA. 1998;280:1311–6. doi: 10.1001/jama.280.15.1311.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media B.V. 2008

Authors and Affiliations

  • Thilo Bertsche
    • 1
    • 2
  • Dorothee Niemann
    • 1
    • 2
  • Yvonne Mayer
    • 1
    • 2
  • Katrin Ingram
    • 1
    • 2
  • Torsten Hoppe-Tichy
    • 2
    • 3
  • Walter E. Haefeli
    • 1
    • 2
    Email author
  1. 1.Department of Internal Medicine VI, Clinical Pharmacology and PharmacoepidemiologyUniversity of HeidelbergHeidelbergGermany
  2. 2.Cooperation Unit Clinical PharmacyUniversity of HeidelbergHeidelbergGermany
  3. 3.Pharmacy DepartmentUniversity Hospital of HeidelbergHeidelbergGermany

Personalised recommendations