9/9/02

Bob Lowry, 334/844-9999

AU STUDY FINDS HOSPITAL MEDICATION ERROR RATE OF 19 PERCENT

AUBURN -- A new study released Monday by an Auburn University researcher showed that medication errors were found in nearly one of five doses administered in 36 health care facilities in Colorado and Georgia.

The results of the study by Kenneth Barker, Sterling Distinguished Professor in AU's School of Pharmacy and director of AU's Center for Pharmacy Operations Design, were published in the Archives of Internal Medicine, a publication of the American Medical Association.

Barker's study, supported by a grant from the Alabama Quality Assurance Foundation in Birmingham, said that physicians who reviewed the data from 1999 said that 7 percent of the medication errors were "rated potentially harmful."

In the 36 hospitals and skilled nursing facilities in Colorado and Georgia, 605 of the 3,216 doses or 19 percent were in error, according to the study. Each of the mistakes were witnessed and verified by a research pharmacist.

Among the most frequent errors made were wrong time (43 percent), omission (30 percent), wrong dose (17 percent) and unauthorized drug (4 percent).

Although it was unclear why, the study said error rates were higher in Colorado than Georgia. The facilities observed in the study were in the Atlanta metropolitan area and the Denver-Boulder-Greeley, Colo., consolidated metro statistical area.

In the direct observation method used in Barker's study -- which he calls "the gold standard," a pharmacist or nurse trained as an observer accompanies a nurse as she prepares the medication and witnesses its administration to the patient, recording exactly what is given the patient without knowing of the accuracy of the medication or the dosage.

The same day, the observer reviews the patient's chart for discrepancies, which are tallied as errors.

Barker said 26 health care facilities in the Atlanta-Denver area declined to participate in the study, but they were randomly replaced by other facilities that volunteered.

"The error rates are likely to be understated because of the large proportion of facilities that declined to participate," the study said. "This evidence of a high rate of medication errors in many of the institutions in the sample supports the implications of the Institute of Medicine report that the medication delivery and administration systems of the nation's hospitals have major systems problems.

"These results are especially valuable because they provide data from primarily nonteaching sites, complementing data from large teaching hospitals, and examine the association of accreditation with error rates."

Barker, who came to Auburn in 1975, is recognized as one of the nation's leading innovators in pharmacy care systems. He has been a national leader in the development and assessment of the unit-dose medication distribution system, a safety system designed to ensure proper dosages for hospital patients, eliminate drug-therapy errors and improve the effective use of nurses.

"Our center (for Pharmacy Operations Design) was created for the conduct of multidisciplinary research on medication systems such as this study," said Barker.

In 1998, American Druggist magazine named Barker one of the nation's "50 Most Influential Pharmacists.

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Other researchers involved in the study included:

** Elizabeth Flynn (Ph.D ), associate research professor in the AU Center for Pharmacy Operations and Designs. Flynn has received several awards for her research on medication errors and is recognized as a national expert on the effect of the physical environment on errors. She recently published a methodological paper based on this study.

** Ginette Pepper (Ph.D ) of the Colorado Health Sciences Center's School of Nursing at Denver. Pepper is a national expert on medication errors from the nursing viewpoint.

** Dr. David Bates of the Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital; and the Center for Applied Medical Information Systems, Partners Healthcare and Harvard Medical School. Bates is a national expert on medical errors as a physician.

** Robert Mikeal (Ph.D ) of DACE Co, West Monroe, La. Mikeal is an expert in experimental design and statistics.

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CONTACT: Barker, 334/844-5152 or 334/821-8050.