Drug administration errors in an institution for individuals with intellectual disability: an observational study.
In ID homes, one in four doses are given wrong—especially via feeding tube—and none are caught by voluntary reports.
01Research in Context
What this study did
Staff watched every drug round in one large home for people with intellectual disability. They noted each step and compared it to the prescription.
The team also checked whether any mistakes had been filed in the home’s own incident reports.
What they found
One in four doses were wrong. Feeding-tube and inhaler medicines were the worst.
Not a single error showed up in the home’s voluntary reports. Staff did not notice or did not record them.
How this fits with other research
Austin et al. (2015) zoomed in on feeding-tube doses in Belgian homes and saw the same pattern: staff skipped dilution, mixed drugs, and flushed poorly. Their work extends the 2007 warning by showing the mistakes are still common eight years later.
Rose et al. (2000) and de Kuijper et al. (2010) show why the errors matter. They found that challenging behavior, not psychosis, drives most antipsychotic prescriptions in ID homes. When the wrong dose reaches a resident, the drug may be unnecessary to start with.
Scheifes et al. (2016) add the next chapter: four out of five adults on these drugs suffer side-effects that hurt quality of life. Together the papers form a chain: high off-label use → frequent administration errors → avoidable harm.
Why it matters
If you work in a residential site, do not trust the incident folder to tell you medication is safe. Watch a few doses yourself, especially feeding-tube and inhaler routes. Spot-check flush steps, dilution, and whether the drug is even needed. A quick direct observation can catch the 25 % that never get reported.
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02At a glance
03Original abstract
BACKGROUND: Medication errors can result in harm, unless barriers to prevent them are present. Drug administration errors are less likely to be prevented, because they occur in the last stage of the drug distribution process. This is especially the case in non-alert patients, as patients often form the final barrier to prevention of errors. Therefore, a study was set up aimed at identifying the frequency of drug administration errors and determinants for these errors in an institution for individuals with intellectual disability (ID). METHODS: This observational study ('disguised observation') was conducted within an institution in the Netherlands caring for 2500 individuals with ID and lasted from October to December 2004 with a case control design for identifying determinants for errors. The institution consists of both day care units and living units (providing full-time care), located in different towns. For the study, five units from different towns were selected. Within each study unit, the administration of drugs to patients was observed for 2 weeks. In total, 953 drug administrations to 46 patients (25 male, mean age 25.8 years, range 2-73 years) were observed. RESULTS: With inclusion of wrong time errors, 242 administrations with at least one error were observed [frequency=242/953 (25.4%)] and with exclusion 213 administrations with at least one error were observed [frequency=213/953 (22.4%)]. Determinants associated with errors were routes of administration 'oral by feeding tube' (OR 189.66; 95% CI 46.16-779.24) and 'inhalation' (OR 9.98; 95% CI 4.78-20.80), the units 'adult full-time care' (OR 2.12; 95% CI 1.05-4.35) and 'children daytime care' (OR 10.80; 95% CI 4.43-26.29) and the absence of a distribution robot (OR 4.0; 95% CI 2.67-5.95). None of the identified errors were reported to the voluntary reporting system. CONCLUSION: This study shows that administration errors in an institution for individuals with ID are common and that they are not formally reported to the voluntary reporting system. Furthermore, it identified some determinants that may be the focus for future improvements aimed to reduce error frequency.
Journal of intellectual disability research : JIDR, 2007 · doi:10.1111/j.1365-2788.2006.00919.x