Medication Prescribing Errors Involving the Route of Administration

Context Administration of medications by the wrong route or as a wrong dose for the ordered route presents significant risk for adverse drug events. Objective To quantify and identify the characteristics of prescribing errors involving the route of drug administration. Design Evaluation of medication orders with errors involving the route of administration detected by pharmacists in a 631-bed tertiary care teaching hospital over a 42-month period. Main Outcome Measures Type, frequency, characteristics, potential for adverse effects, contributors, and enabling factors of medication prescribing errors involving the route of administration. Results A total of 862 prescribing errors were detected. Sixty-one different types of route-related prescribing errors, involving 135 different medications, were detected. The most common type of these errors involved prescribing the wrong route of administration (39.2%) and prescribing the same or similar medications to be given concurrently by two routes (21.1 %). The most common class of medications involved were cardiovascular agents (23.5%). The most common medication characteristic identified as contributing to route-related prescribing errors was the common and routine use of a drug by multiple routes (75.9%). Conclusions Prescribing errors involving the route of administration are common, occur in a wide variety of ways, and involve a wide variety of medications. A number of commonly recommended medication safety practices should reduce risk to patients from route-related medication prescribing errors.