Drug administration errors in an institution for individuals with intellectual disability: an observational study

• Published in: Journal of intellectual disability research Vol. 51; no. 7; pp. 528 - 536
• Main Authors: Van Den Bemt, P. M. L. A., Robertz, R., De Jong, A. L., Van Roon, E. N., Leufkens, H. G. M.
• Format: Journal Article
• Language: English
• Published: Oxford, UK Blackwell Publishing Ltd 01.07.2007; Blackwell Publishing; Blackwell; Wiley Subscription Services, Inc
• Subjects: Adolescent; Adult; Aged; Biological and medical sciences; Child; Child, Preschool; Critical incidents; drug administration errors; Drug Therapy; Drug toxicity and drugs side effects treatment; Drugs; Error Patterns; Female; Foreign Countries; Humans; Incidence; Institution therapy. Inpatient treatment; Intellectual Disability; Intellectual Disability - epidemiology; intellectual disability introduction; Learning disabilities; Learning disabled people; Male; Medical errors; Medical sciences; Medication Errors - statistics & numerical data; medication safety; Mental Retardation; Middle Aged; Miscellaneous (drug allergy, mutagens, teratogens...); Netherlands; Observation; Patient safety; Patients; Pharmacology; Pharmacology. Drug treatments; Prospective Studies; Psychology. Psychoanalysis. Psychiatry; Psychopathology. Psychiatry; Residential care; Studies; Treatments; Netherlands; Europe; Social environment; Handicap; Human; medication safety; Toxicity; drug administration errors; Mental health; Error rate; Specialized institution; Pharmacotherapy; Developmental disorder; Case control study; Route of administration; Mental retardation; Chemotherapy; Treatment; intellectual disability introduction; Risk factor; Intellectual deficiency; Application method; Public health
• ISSN: 0964-2633; 1365-2788
• DOI: 10.1111/j.1365-2788.2006.00919.x

Background  Medication errors can result in harm, unless barriers to prevent them are present. Drug administration errors are less likely to be prevented, because they occur in the last stage of the drug distribution process. This is especially the case in non‐alert patients, as patients often form the final barrier to prevention of errors. Therefore, a study was set up aimed at identifying the frequency of drug administration errors and determinants for these errors in an institution for individuals with intellectual disability (ID). Methods  This observational study (‘disguised observation’) was conducted within an institution in the Netherlands caring for 2500 individuals with ID and lasted from October to December 2004 with a case control design for identifying determinants for errors. The institution consists of both day care units and living units (providing full‐time care), located in different towns. For the study, five units from different towns were selected. Within each study unit, the administration of drugs to patients was observed for 2 weeks. In total, 953 drug administrations to 46 patients (25 male, mean age 25.8 years, range 2–73 years) were observed. Results  With inclusion of wrong time errors, 242 administrations with at least one error were observed [frequency = 242/953 (25.4%)] and with exclusion 213 administrations with at least one error were observed [frequency = 213/953 (22.4%)]. Determinants associated with errors were routes of administration ‘oral by feeding tube’ (OR 189.66; 95% CI 46.16–779.24) and ‘inhalation’ (OR 9.98; 95% CI 4.78–20.80), the units ‘adult full‐time care’ (OR 2.12; 95% CI 1.05–4.35) and ‘children daytime care’ (OR 10.80; 95% CI 4.43–26.29) and the absence of a distribution robot (OR 4.0; 95% CI 2.67–5.95). None of the identified errors were reported to the voluntary reporting system. Conclusion  This study shows that administration errors in an institution for individuals with ID are common and that they are not formally reported to the voluntary reporting system. Furthermore, it identified some determinants that may be the focus for future improvements aimed to reduce error frequency.