Antiretroviral Medication Errors in a National Medication Error Database

Abstract

Antiretroviral medications have reduced the morbidity and mortality associated with HIV. In contrast to these benefits, medication errors involving antiretrovirals represent opportunities for causing harm. We analyzed 400 medication errors that involved at least one single or combined HIV antiretroviral product that had been reported to a national medication error reporting program (MEDMARX). Our analysis revealed that 3% of the errors were harmful. Most of the errors (45%) occurred in the dispensing phase of the medication use process, a finding that differs significantly from many published studies. The most frequent types of errors were wrong dose (37.5%) and wrong medication (32%). Lamivudine (Epivir, Glaxo-SmithKline, Research Triangle Park, NC) was the most commonly identified product to be involved in the errors. Community hospitals were more likely to have prescribing errors than teaching hospitals. Similar brand and generic names were associated with many of the errors. With frequent dosing of many HIV medications, health care organizations must have a process to clarify orders rapidly and maintain current references (including photos) of antiretrovirals. Prescribers should clearly spell out the intended product and avoid abbreviations. Participating in voluntary medication error reporting programs increases the awareness of the threats of medication errors involving antiretrovirals.

Evaluation of antiretroviral-related errors and interventions by the clinical pharmacist in hospitalized HIV-infected patients

“…We found that, in total, dose‐related problems (incorrect dose, dose omission, and lack of dose adjustment in patients with renal or hepatic impairment) accounted for 43.3% of all errors. This result is comparable to those of Mok et al [4] and Gray et al [15]…”

“…We found that, in total, dose-related problems (incorrect dose, dose omission, and lack of dose adjustment in patients with renal or hepatic impairment) accounted for 43.3% of all errors. This result is comparable to those of Mok et al [4] and Gray et al [15] Risk factors associated with a HAART-related error in our study were similar to those found by Mok et al [4]: renal impairment, an atazanavir-containing regimen, and admission by a service other than the infectious diseases service. We also found that receiving a nonnucleoside reverse transcriptase inhibitor was a protective factor.…”

“…In seven admissions (3.3%) there was an unexplained delay in continuing HAART. Gray et al [15] analysed the causes of HIV medication errors in MEDMARX, a voluntary database reporting inpatient medication errors. They found that the most common causes of error were inappropriate dosing (38%), followed by incorrect medication (32%).…”

Frequency of HIV-Related Medication Errors and Associated Risk Factors in Hospitalized Patients

“…One of the main proposed contributors to this difference is the retrospective nature of most prior studies. 11–13 In our investigation, patients were actively tracked on a daily basis from admission until discharge by experienced HIV specialized pharmacists, increasing the sensitivity with which errors were identified and corrected. This unexpectedly high frequency of errors also compromised our subsequent risk factor analysis, since the majority of patients had the outcome of interest, thus making it difficult to discern statistically significant associations in our relatively small sample size.…”

Nucleoside Reverse-Transcriptase Inhibitor Dosing Errors in an Outpatient HIV Clinic in the Electronic Medical Record Era

“…This study of NRTI prescriptions at a university-based HIV clinic using an EMR found errors in 6% of prescriptions overall and in 31% of prescriptions for patients with renal impairment. Previous studies, conducted among HIV-infected inpatients, have identified nonstandard dosing (i.e., overdosing, underdosing, or incorrect frequency of dosing) as the most common error type and have identified lamivudine as the NRTI most frequently associated with prescribing errors [2][3][4][5][6], compared with the findings in our study that a lack of dose adjustment for patients with renal impairment was the most common error and that didanosine was the NRTI most frequently associated with prescribing errors. Because didanosine was the only NRTI for which all 4 defined error types could occur, the complexity of didanosine dosing, relative to dosing with other NRTIs, might explain the higher risk of errors associated with this drug.…”