Medication Errors in Hospitalized Cardiovascular Patients

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Abstract
THE INSTITUTE of Medicine's report To Err Is Human: Building a Safer Health System1 estimates that tens of thousands of people die and hundreds of thousands of people experience nonfatal injuries each year in the United States as the result of medical errors, particularly those involving medications. Based on the work of Leape and colleagues,2 the report also recommends pharmacist participation in patient rounds as an immediate approach to reducing medication errors. To better understand the potential for pharmacist interventions to identify and prevent medication errors, we systematically examined the interventions of the clinical pharmacist (N.M.A.L.) who routinely participated in medical rounds on the cardiology and electrophysiology services at Duke University Hospital between September 1, 1995, and February 18, 2000. A significant association between severe adverse drug events (ADEs) and cardiovascular drugs has been described.3 Recognizing this potential harm from cardiovascular medication errors, a clinical pharmacist has been a regular member of the cardiology service for more than 2 decades. Medication errors were recorded and classified according to the type of error, medications involved, personnel involved, stages of drug administration involved, and time of year most frequently associated with errors.