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Patricia L. Cornish, BScPhm; Sandra R. Knowles, BScPhm; Romina Marchesano, BSc(Hon); Vincent Tam, BSc(Hon); Steven Shadowitz, MD, FRCPC; David N. Juurlink, MD, FRCPC; Edward E. Etchells, MD, FRCPC

Arch Intern Med. 2005;165:424-429.

Background  Prior studies suggest that unintended medication discrepancies that represent errors are common at the time of hospital admission. These errors are particularly worthy of attention because they are not likely to be detected by computerized physician order entry systems.

Methods  We prospectively studied patients reporting the use of at least 4 regular prescription medications who were admitted to general internal medicine clinical teaching units. The primary outcome was unintended discrepancies (errors) between the physicians’ admission medication orders and a comprehensive medication history obtained through interview. We also evaluated the potential seriousness of these discrepancies. All discrepancies were reviewed with the medical team to determine if they were intentional or unintentional. All unintended discrepancies were rated for their potential to cause patient harm.

Results  After screening 523 admissions, 151 patients were enrolled based on the inclusion criteria. Eighty-one patients (53.6%; 95% confidence interval, 45.7%-61.6%) had at least 1 unintended discrepancy. The most common error (46.4%) was omission of a regularly used medication. Most (61.4%) of the discrepancies were judged to have no potential to cause serious harm. However, 38.6% of the discrepancies had the potential to cause moderate to severe discomfort or clinical deterioration.

Conclusions  Medication errors at the time of hospital admission are common, and some have the potential to cause harm. Better methods of ensuring an accurate medication history at the time of hospital admission are needed.

Author Affiliations: Departments of Pharmacy (Mss Cornish and Knowles) and General Internal Medicine (Drs Shadowitz, Juurlink, and Etchells) and Patient Safety Service (Mss Cornish and Knowles and Dr Etchells), Sunnybrook and Women’s College Health Sciences Centre, and Faculty of Pharmacy, University of Toronto (Ms Marchesano), Toronto; and Faculty of Medicine, University of Ottawa, Ottawa (Mr Tam); Ontario.

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