Analgesic-Related Medication Errors Reported to US Poison Control Centers

• Published in: Pain medicine (Malden, Mass.) Vol. 19; no. 12; pp. 2357 - 2370
• Main Authors: Eluri, Madhulika, Spiller, Henry A, Casavant, Marcel J, Chounthirath, Thitphalak, Conner, Kristen A, Smith, Gary A
• Format: Journal Article
• Language: English
• Published: England Oxford University Press 01.12.2018
• Subjects: Acetaminophen; Acetaminophen - therapeutic use; Adolescent; Adult; Aged; Aged, 80 and over; Analgesics; Analgesics - adverse effects; Analgesics, Opioid - therapeutic use; Anti-inflammatory agents; Anti-Inflammatory Agents, Non-Steroidal - therapeutic use; Child; Child, Preschool; Children; Databases, Factual - statistics & numerical data; Female; GENERAL & SELECTED POPULATIONS SECTION; Government policy; Human error; Humans; Infant; Inflammation; Male; Medical errors; Medication Errors - statistics & numerical data; Middle Aged; Narcotics; Opioids; Poison control centers; Poison Control Centers - statistics & numerical data; Retrospective Studies; Young Adult; Opioid; Poisoning; Analgesic; Acetaminophen; Poison Control Center; Ibuprofen
• ISSN: 1526-2375; 1526-4637
• DOI: 10.1093/pm/pnx272

Abstract Objective This study investigates the characteristics and trends of medication errors involving analgesic medications. Design and Methods A retrospective analysis was conducted of analgesic-related medication errors reported to the National Poison Data System (NPDS) from 2000 through 2012. Results From 2000 through 2012, the NPDS received 533,763 reports of analgesic-related medication errors, averaging 41,059 medication errors annually. Overall, the rate of analgesic-related medication errors reported to the NPDS increased significantly by 82.6% from 2000 to 2009, followed by a 5.7% nonsignificant decrease from 2009 to 2012. Among the analgesic categories, rates of both acetaminophen-related and opioid-related medication errors reported to the NPDS increased during 2000–2009, but the opioid error rate leveled off during 2009–2012, while the acetaminophen error rate decreased by 17.9%. Analgesic-related medication errors involved nonsteroidal anti-inflammatory drugs (37.0%), acetaminophen (35.5%), and opioids (23.2%). Children five years or younger accounted for 38.8% of analgesics-related medication errors. Most (90.2%) analgesic-related medication errors were managed on-site, rather than at a health care facility; 1.6% were admitted to a hospital, and 1.5% experienced serious medical outcomes, including 145 deaths. The most common type of medication error was inadvertently taking/given the medication twice (26.6%). Conclusion Analgesic-related medication errors are common, and although most do not result in clinical consequences, they can have serious adverse outcomes. Initiatives associated with the decrease in acetaminophen-related medication errors among young children merit additional research and potential replication as a model combining government policy and multisectoral collaboration.