Analysis of MEDMARX data found that computerized systems did not prevent errors associated with dispensing and administering medications.

The use of patient-controlled analgesia (PCA) is an important method to treat pain, but concerns about its safety and device selection have been raised. This study examined nearly 10,000 PCA-related medication errors submitted to MEDMARX, a database that tracks medication information from participating hospitals. Investigators discovered that patient harm was associated with 6.5% of the errors, and the errors overall were reported across all phases of the medication process. The most common errors were related to improper dosage or quantity. An AHRQ WebM&M commentary discusses a case of a PCA overdose and the mechanisms to promote its safe use.

Warfarin therapy is frequently associated with adverse drug events. Past efforts to identify potential prevention strategies have focused on using specific indicators or triggers to detect such events. This study examined more than 9000 errors in warfarin use submitted voluntarily through MEDMARX, a database that tracks medication information from participating hospitals. Investigators discovered that inpatient warfarin-related errors occurred most frequently during transcription/documentation and administration, while outpatient errors occurred most frequently during prescribing and dispensing. Using warfarin data as an example, the authors discuss the utility of voluntary error reporting systems and outline the limitations in their use.

Avoiding use of unclear or misleading abbreviations is a key step in preventing medication prescribing errors, and the Joint Commission mandates avoiding specific abbreviations as one of its National Patient Safety Goals. This study analyzed Medmarx data from 2004 to 2006 to determine the prevalence and impact of errors related to abbreviations. Despite dissemination of the Joint Commission's “do not use” abbreviation list, errors involving these abbreviations occurred more than 18,000 times during the study period, although few patients were harmed as a result.

The author discusses the role that human error plays in the failure of technological solutions employed to minimize medical mistakes.

This study examined data from a voluntary medication error reporting system (Medmarx) to determine the incidence of harmful pediatric medication errors, the classes of medications frequently associated with error, and the types of errors that occurred. Harmful errors were defined as errors that resulted in temporary or permanent harm to the patient or required immediate intervention to avoid harm. Opioid analgesics, antimicrobials, and antidiabetic agents were most commonly associated with harmful medication errors, collectively accounting for 23.5% of the errors reported. The major type of error was administration at an incorrect dose or quantity (especially for opioid analgesics), followed by omission errors. These findings are similar to those of a previous study. The authors review the systems factors contributing to common medication errors and suggest strategies for error prevention.

The author analyzes error data submitted to Medmarx over a 5-year period and makes recommendations for the safe use of neuromuscular blocking agents.

Medication reconciliation represents an active effort of hospitals across the country to comply with recent additions to JCAHO's National Patient Safety Goals. Using data captured from USP's Medmarx program, this study discusses the errors that resulted after implementing a medication reconciliation process. Based on analysis of more than 2000 reconciliation-related errors, the author presents the distribution of errors by category (eg, potential error, intercepted error), types of errors (eg, improper dose, wrong drug, wrong time), and leading causes and contributing factors. The author also provides case examples for reconciliation errors at admission, transfer of care, and discharge. A past study also discussed practical strategies for implementing medication reconciliation processes.

The investigators from the Agency for Healthcare Research and Quality (AHRQ) and United States Pharmacopeia (USP) compared MedMarx reports from facilities using computerized prescriber order entry (CPOE) with those utilizing conventional methods of ordering.

The authors use data from United States Pharmacopeia Medication Errors Reporting Program to illustrate look-alike/sound-alike errors and provide strategies to minimize their occurrence.

This study analyzed US Pharmacopeia's MEDMARX error-reporting database to describe characteristics of medication errors resulting from wrong administration techniques. The authors discuss the severity of errors captured and their location of origin, in addition to the most frequent contributing factors, which included performance deficit and failure to follow a protocol. Drawing from more than 7200 wrong administration technique errors, a number of true case examples are provided to illustrate the nature and scope of the problem. The authors conclude with a series of recommendations focused on greater training in administration techniques (eg, infusion pumps and dispensing devices) as well as education on a number of high-risk medications implicated in the findings.

Using Medmarx data from 2001 through 2003, the authors analyze pediatric medication errors and provide suggestions for minimizing errors in pediatric patients.