Therapeutic errors involving adults in the community setting: nature, causes and outcomes
Article first published online: 4 AUG 2009
© 2009 The Authors. Journal Compilation © 2009 Public Health Association of Australia
Australian and New Zealand Journal of Public Health
Volume 33, Issue 4, pages 388–394, August 2009
How to Cite
Taylor, D. M., Robinson, J., MacLeod, D., MacBean, C. E. and Braitberg, G. (2009), Therapeutic errors involving adults in the community setting: nature, causes and outcomes. Australian and New Zealand Journal of Public Health, 33: 388–394. doi: 10.1111/j.1753-6405.2009.00413.x
- Issue published online: 4 AUG 2009
- Article first published online: 4 AUG 2009
- Submitted: October 2008 Revision requested: March 2009 Accepted: May 2009
- Therapeutic error;
- medication error;
- adverse event
Objective: To compare the nature of therapeutic errors made by adults in community residential units (CRU) and private homes (Home).
Methods: This was an analytical case series of therapeutic errors, involving adults, reported to the Victorian Poisons Information Centre (January 2006 to March 2007). The main outcome measures were the nature, causes and outcomes of the errors and actions taken or recommendations for avoidance.
Results: Ninety-seven CRU and 611 Home residents (cases) were enrolled. These groups took 243 (median 2) and 785 (median 1) medications in error, respectively (p<0.001). The medication administrators were predominately staff members (94.8%) and the cases themselves (95.9%), respectively (p<0.001). The CRU cases more frequently had an incorrect medication(s) or another person's medication(s) and the Home cases a double dose or incorrect dose (p<0.001). Wide ranges of medications were taken in error with cardiac and respiratory medications being more common among the Home cases. Four (4.1%, 95% CI 1.3-10.8) CRU and 16 (2.6%, 95% CI 1.6-4.3) Home cases were referred to hospital. No case followed up had a serious outcome. Error cause differed significantly between the groups (p<0.001). Staffing issues and human factors were common within the CRU and Home groups, respectively.
Conclusions: Therapeutic errors in the community are preventable and differ considerably between the CRU and Home settings.
Implications: Prevention initiatives are indicated with particular attention to CRU staffing, training and procedural issues.