Medication Events on a Tertiary Neurology Inpatient Service (P07.239)

Objective: To describe medication events occurring on neurological hospital services. Background Medication events are common in hospitalized patients. Relatively little is known about the characteristics of medication events on neurology inpatient services. Design/Methods: Medication events reported on inpatient neurology services (general neurology, epilepsy monitoring unit, cerebrovascular service, and neurological ICU) were reviewed from January 1, 2009 through December 31, 2010 in a 1,265-bed tertiary care center. Data collection was through a pre-established institutional voluntary event recording system. Reportable events included any event that was an undesired occurrence that caused or had the potential to cause injury. Results: 143 medication events were reported, for a rate of 8.6 events per 1000 patient days. There were no trends associated with time of day or month of the year. Of these, 118 (82.5%) reached the patient; 103 (72%) did not require intervention. The most common medication types involved were anticoagulants (24 events, 16.8%), anticonvulsants (17 events, 11.9%), and antibiotics (16 events, 11.2%). The most common types of events were medication omission (27 events, 18.9%) and wrong medication dose/rate (26 events, 18.2%). The most common step in which an event occurred was administration (77 events, 53.8%). Nurses were involved in reporting 133 events (93%), while physicians were involved in reporting 20 events (14%). Conclusions: Medication events were not uncommon on our neurology inpatient services, and most commonly involved anticoagulants, anticonvulsants and antibiotics. No trends referable to time of year or day were identified to suggest an association with the academic calendar or call coverage. Nursing staff reported the majority of events, suggesting a stronger culture of event reporting in non-physician providers on out unit. Disclosure: Dr. Williams has nothing to disclose. Dr. Sweeney has nothing to disclose. Dr. Britton has received personal compensation for activities with Cyberonics, Inc. as a consultant.