• Bradley K Weiner, James Venarske, Mona Yu, and Kenneth Mathis.
• Division of Spinal Surgery, Department of Orthopaedic Surgery, The Methodist Hospital, Houston, TX 77030, USA. bkweiner@tmh.tmc.edu
• Spine. 2008 Jan 1; 33 (1): 104-7.

Study DesignEvaluation of medication ordering errors discovered on an orthopedic/spinal in-patient hospital unit and efforts initiated to reduce them. OBJECTIVE.: In this study the authors aimed to assess the frequency of medication ordering errors and to examine the impact of local measures set forth to reduce their occurrence.Summary Of Background DataSince the release of the 2000 Institute of Health report: "To Err is Human"; in-hospital medical errors have been recognized as being unacceptably high; the consequence being preventable death rates estimated near 125,000 patients per year. The most common of errors are those involving medications.MethodsThe study consisted of 2 parts. In part 1, the charts from 82 consecutive patients admitted to the Orthopedic/Spine Surgical Unit were assessed to determine the frequency, type, and potential severity of medication ordering errors. Several programs to reduce such errors were subsequently instituted and included: improved chart surveillance by pharmacists, a newly developed medication/history form given to and reviewed with patients before surgery, in-service education of preoperative nursing staff, patient database form changes, and requests for patients to bring their medications on admission. Part 2, including 87 patients, assessed the impact of these measures.ResultsIn part 1, medication errors were detected in 62% of orders overall. Of these, 43% were found to be of moderate or high potential for harm. After the institution of the above measures (part 2), overall errors were reduced by 31%; moderate/high risk potential harm was reduced by 64%; and errors of omission were detected twice as often.ConclusionMedication errors in ordering are common in orthopedics. We found in part 1 that a chart review and patient interview by the pharmacy team can detect and correct these before reaching the patient. Furthermore, we found in part 2 that the risk could be further reduced by the implementation of pharmacist-led: patient education, education of preoperative nursing personnel, improvement of forms used for data collection, and having the patients bring all of their medications on admission.

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