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When and how inpatient medication errors occur

Hospitalist Leadership Connection, August 19, 2008

During a hospital stay, inpatients experience an average of about 1.5 errors in their medication report that can potentially harm them, according to a new study from Brigham and Women’s Hospital (BWH) and Massachusetts General Hospital. The study highlights deficiencies in inpatient medication reconciliation; that is, how and when a breakdown occurs in the process of identifying a patient’s complete list of medications. Most errors include omissions; incorrect dosage, frequency, substations, and medication combinations were also among common discrepancies, according to the BWH press release on Thursday. Most errors—72% percent of potentially harmful discrepancies—occur while taking the patient’s medication history. By contrast, only 26% of medication history errors occur during discharge, although discharge medicine mistakes can be more serious than admission errors.

“With patients today on more medications than in days past, the stakes are higher than ever before,” said Jeffrey Schnipper, MD, MPH, senior author and hospitalist at BWH, in the press release. “Knowing when and where to look for discrepancies will help hospitals prevent errors that could cause harm to patients,” he said.

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