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Medication errors occurring at the time of hospital admission are common and not likely to be detected by computerized prescriber order entry systems, according to Canadian researchers.


The researchers studied 151 patients admitted to a general internal medicine unit who reported using at least four prescription medications. They found that 81 patients (54%) had at least one medication discrepancy, the most common being omission of a regularly used medication.

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As part of the study, researchers conducted a comprehensive interview with each patient about her medication history. They also checked with health care providers to determine which discrepancies were unintended.


Researchers identified 140 unintended discrepancies between the physicians' admission medication orders and the patient's medication history. These included 65 drug omissions, 16 incorrect drugs, and 59 incorrect doses or frequencies. Errors were no more likely to occur during weekend or night admissions or periods of high workload than at other times.


Most of the errors were judged to have no potential to cause serious harm, but 39% could have caused moderate to severe discomfort or clinical deterioration. About 6% could have caused severe consequences.


The researchers conclude that hospitals need better ways to ensure an accurate medication history at admission. Advise patients to keep an accurate, current list of all their medications and to take the list to the hospital with them.




Unintended medication discrepancies at the time of hospital admission, Archives of Internal Medicine, PL Cornish, et al., February 28, 2005.