Despite antiretroviral medication errors being a common
occurrence upon hospital admission among patients with HIV, they are typically
corrected within 48 hours, according to study findings published in Clinical
Prior research suggests that ART medication errors
are on the rise, researchers from the University of Pennsylvania wrote in
the study. In 1998, ART medication errors were detected in 12% of
admissions; but between 2004 and 2007, the error rate had increased to between
21% and 26% of admissions.
For the retrospective review, researchers pooled data on
medication orders during the first 48 hours of 702 hospitalizations for
patients with HIV admitted to one hospital in 2009. Four possible errors were
classified as: incomplete regimen, incorrect dosage non-recommended
drug-to-drug combo and incorrect schedule.
Of the 380 patients with ART prescribed on day 1 of
hospital admission, there were 145 ART medication errors among 110 admissions.
Of the 308 patients with ART administered on the second day of hospital
admission, the researchers identified 22 errors among 21 admissions.
On the first day, the most common error was incomplete
regimen, followed by incorrect dosage. In the dosing errors, 70% occurred in
protease inhibitors and 30% involved nucleoside/nucleotide reverse
transcriptase inhibitors. On the second day of hospitalization, half of the
errors were due to incorrect dosage, according to the researchers.
New interventions, both educational and
technological, and clinical pharmacist coverage during evening and weekend
hours are needed to safeguard patients and prevent the serious complications of
antiretroviral medication errors, especially during the first 24 hours of
admission, the researchers wrote.
- Yehia BR. Clin Infect Dis. 2012;doi:10.1093/cid/cis491.
- The researchers report no relevant disclosures.