Antiretroviral Medication Errors in a National Medication Error Database

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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.

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