• Madhulika Eluri, Henry A Spiller, Marcel J Casavant, Thitphalak Chounthirath, Kristen A Conner, and Gary A Smith.
• Center for Injury Research and Policy at Nationwide Children's Hospital, Columbus, Ohio.
• Pain Med. 2018 Dec 1; 19 (12): 235723702357-2370.

ObjectiveThis study investigates the characteristics and trends of medication errors involving analgesic medications.Design And MethodsA retrospective analysis was conducted of analgesic-related medication errors reported to the National Poison Data System (NPDS) from 2000 through 2012.ResultsFrom 2000 through 2012, the NPDS received 533,763 reports of analgesic-related medication errors, averaging 41,059 medication errors annually. Overall, the rate of analgesic-related medication errors reported to the NPDS increased significantly by 82.6% from 2000 to 2009, followed by a 5.7% nonsignificant decrease from 2009 to 2012. Among the analgesic categories, rates of both acetaminophen-related and opioid-related medication errors reported to the NPDS increased during 2000-2009, but the opioid error rate leveled off during 2009-2012, while the acetaminophen error rate decreased by 17.9%. Analgesic-related medication errors involved nonsteroidal anti-inflammatory drugs (37.0%), acetaminophen (35.5%), and opioids (23.2%). Children five years or younger accounted for 38.8% of analgesics-related medication errors. Most (90.2%) analgesic-related medication errors were managed on-site, rather than at a health care facility; 1.6% were admitted to a hospital, and 1.5% experienced serious medical outcomes, including 145 deaths. The most common type of medication error was inadvertently taking/given the medication twice (26.6%).ConclusionAnalgesic-related medication errors are common, and although most do not result in clinical consequences, they can have serious adverse outcomes. Initiatives associated with the decrease in acetaminophen-related medication errors among young children merit additional research and potential replication as a model combining government policy and multisectoral collaboration.

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