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Double Dose at Transfer

Jeffrey L. Hackman, MD | May 1, 2012
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The Case

A 74-year-old man with history of diabetes and hypertension was admitted to the emergency department (ED) for left lower extremity pain, swelling, and erythema. The ED physician made the diagnosis of cellulitis and prescribed vancomycin, 1 g IV every 12 hours. The patient's first dose was administered in the ED.

Approximately 6 hours after admission to the ED (and just 3 hours after receipt of his first vancomycin dose), the patient was transferred to a medical–surgical floor. The admitting nurse noted the vancomycin order on the admission order set and—unaware that the patient had received a dose in the ED—administered another dose.

Physicians may write "delayed admission orders" that are activated upon ward admission. However, in patients with longer ED stays, some of those delayed admission orders are carried out in the ED. In this instance, the respective ED and ward systems were not linked, limiting tracking of medication administration in the respective units. Similarly, the pharmacy system at this hospital did not capture outpatient versus ED versus ward dispensing of medications.

A physician who was aware the patient had received a dose of vancomycin in the ED realized the mistake and ordered a serum vancomycin level. While the patient was confirmed to have an elevated level, he experienced no associated toxicities, and his dosing resumed on the appropriate schedule.

The Commentary

It is well documented that medication errors are common and often have significant adverse effects on patients.(1) The incidence of preventable adverse drug events (ADEs) varies, but some of the estimates cited in the Institute of Medicine report, To Err is Human, include 1.81 significant errors per 1000 orders (2), 1.82 preventable ADEs per admission among non-obstetrical admissions (3), and one error resulting in injury per 6.8 admissions to a neonatal or pediatric ICU.(4) More recent studies confirm high rates of medication errors.(5-7)

In this case, a patient awaiting ward admission received an extra dose of vancomycin. Extra dose ADEs are commonly associated with a failure of communication and/or missing information. Despite the emergency department (ED) serving as the entry point for most admissions, a surprising disconnect often exists between the ED and the rest of the hospital. This disconnect may be exacerbated by the hospital's selection of an Emergency Department Information System (EDIS). Many EDs have "best of breed" systems, which may successfully optimize ED care, but do not link with the enterprise-wide system. Even when the ED and hospital system are different, many ED products can be successfully integrated into an enterprise system to promote seamless patient care. Despite this potential for integration, the relative complexity of the systems and their interfaces may result in the decision not to integrate the systems, even if technically possible. In fact, in recent years, the complexity of sharing information, the regulatory landscape, and other factors are leading hospitals and EDs to favor enterprise-wide systems. As evidence, of those hospitals planning to replace or implement an EDIS, 72% reported moving away from a best of breed EDIS product.(8)

An integrated electronic medical record (EMR) is only one step toward reducing extra dose ADEs. The information must be presented such that clinicians clearly recognize which medications have been administered and those that are still due. The current case vividly illustrates the need for this clarification.

The Joint Commission has concluded that breakdown in communication is a very common factor in medication error events.(9) Clear communication at key handoffs, including which orders have been completed and which remain to be carried out, decrease the risk of ADEs.

Medication dispensing devices may provide another safeguard against ADEs.(10,11) Even in the absence of an integrated EMR, automated medication dispensing (AMD) devices can be used throughout the organization. AMD systems can display the time a medication was last removed, regardless of where in the organization this removal took place. Such a system may have prevented receipt of the extra dose of vancomycin in the current case.

Barcoded medication administration (BCMA) is an additional layer of protection against ADEs.(12,13) Similar to AMD systems, BCMA can provide warnings regarding previous medication administration in the presence of an integrated pharmacy system.

Medication errors are complicated and associated with multiple etiologies. Fortunately, several tools are available to reduce the risk of errors. Key stakeholders, including the medical staff, nursing, and pharmacy leadership, should determine those strategies likely to be most effective in their hospital. When implementing any solution, leadership also must be cognizant of the possibility of unintended consequences, including new types of errors or decreased efficiencies. An AMD system should be considered early in the decision making due to easy implementation and significant benefits. Ultimately, deploying an integrated or fully interfaced EHR should be the organizational goal.

Take-Home Points

  • Preventable medication errors remain a relatively common cause of significant morbidity and mortality. These errors can originate from incomplete communication between the ED and other hospital units.
  • Electronic medical records provide both opportunities and risks related to adverse drug events and must be implemented carefully to minimize the risk to patient safety.
  • Multiple technology-based options are available to improve the safety of medication administration in the ED.

Jeffrey L. Hackman, MD

Chief Medical Information Officer

Truman Medical Centers


1. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a Safer Health System. Washington, DC: Committee on Quality of Health Care in America, Institute of Medicine, National Academies Press; 2000. ISBN: 9780309068376.

2. Lesar TS, Briceland L, Stein DS. Factors related to errors in medication prescribing. JAMA. 1997;277:312-317. [go to PubMed]

3. Bates DW, Cullen DJ, Laird N, et al; ADE Prevention Study Group. Incidence of adverse drug events and potential adverse drug events: implications for prevention. JAMA. 1995;274:29-34. [go to PubMed]

4. Raju TNK, Kecskes S, Thornton JP, Perry M, Feldman S. Medication errors in neonatal and paediatric intensive-care units. Lancet. 1989;2:374-376. [go to PubMed]

5. Walsh KE, Landrigan CP, Adams WG, et al. Effect of computer order entry on prevention of serious medication errors in hospitalized children. Pediatrics. 2008;121:e421-e427. [go to PubMed]

6. Ben-Yehuda A, Bitton Y, Sharon P, Rotfeld E, Armon T, Muszkat M. Risk factors for prescribing and transcribing medication errors among elderly patients during acute hospitalization: a cohort, case-control study. Drugs Aging. 2011;28:491-500. [go to PubMed]

7. Zhan C, Hicks RW, Blanchette CM, Keyes MA, Cousins DD. Potential benefits and problems with computerized prescriber order entry: analysis of a voluntary medication error-reporting database. Am J Health Syst Pharm. 2006;63:353-358. [go to PubMed]

8. Emergency Department Information Systems: Is Best of Breed Still the Best Approach? Orem, UT: KLAS; December 15, 2009. [Available at]

9. Sentinel Event Data—Root Causes by Event Type. Oakbrook Terrace, IL: The Joint Commission; March 2012. [Available at]

10. Chapuis C, Roustit M, Bal G, et al. Automated drug dispensing system reduces medication errors in an intensive care setting. Crit Care Med. 2010;38:2275-2281. [go to PubMed]

11. Paparella S. Do not put medication safety "on hold" with boarded patients. J Emerg Nurs. 2010;36:347-349. [go to PubMed]

12. Poon EG, Keohane CA, Yoon CS, et al. Effect of bar-code technology on the safety of medication administration. N Engl J Med. 2010;362:1968-1707. [go to PubMed]

13. Cescon DW, Etchells E. Barcoded medication administration: a last line of defense. JAMA. 2008;299:2200-2202. [go to PubMed]

This project was funded under contract number 75Q80119C00004 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The authors are solely responsible for this report’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the authors has any affiliation or financial involvement that conflicts with the material presented in this report. View AHRQ Disclaimers
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