Medication mistakes are common among patients who have received liver, kidney or pancreas transplants, researchers at the Yale University School of Medicine reported recently.


The team followed 93 outpatients for a year and found 149 errors. The patients were each prescribed an average of 11 medications. Most of the errors were harmless, but 48 of them (32%) resulted in adverse consequences.

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These included hospitalization (17 patients), invasive outpatient procedures (three patients), organ rejection (nine patients) and allograft failures (six patients).


“Outpatient medication errors are abundant, often occult, and associated with significant adverse events in a complex transplant population,” the researchers concluded in Archives of Surgery (2007;142:278-283).


The researchers categorized the errors into five types and ranked their frequency:

  1. Patient errors (failure to accurately use an available, prescribed medication) caused 83 incidents or 56% of the mistakes.
  2. Prescription errors (failure to provide a correct prescription) resulted in 20 incidents or 13% of the total.
  3. Delivery errors (failure to deliver a prescribed medication to the patient) were related to 20 incidents or 13%.
  4. Availability errors (failure to stock enough medication for a 24-hour or greater supply) led to 15 incidents or 10%.
  5. Reporting errors (failure to identify the type, dosage, or frequency of a medication) caused 12 incidents or 8%.

“We should strive to continue to eliminate health care system-based errors through centralized records and other streamlining methods to improve processes,” the researchers wrote. “In doing so, it seems likely that our patients will gain confidence in us and our ability to help them navigate a complex and confusing system.”