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Journal Article

Citation

Eluri M, Spiller HA, Casavant MJ, Chounthirath T, Conner KA, Smith GA. Pain Med. 2018; 19(12): 2357-2370.

Affiliation

Child Injury Prevention Alliance, Columbus, Ohio, USA.

Copyright

(Copyright © 2018, Oxford University Press)

DOI

10.1093/pm/pnx272

PMID

29186557

Abstract

OBJECTIVE: This study investigates the characteristics and trends of medication errors involving analgesic medications. DESIGN AND METHODS: A retrospective analysis was conducted of analgesic-related medication errors reported to the National Poison Data System (NPDS) from 2000 through 2012.

RESULTS: From 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%).

CONCLUSIONS: Analgesic-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.


Language: en

Keywords

Acetaminophen; Analgesic; Ibuprofen; Opioid; Poison Control Center; Poisoning

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