Medication errors when transferring elderly patients between primary health care and hospital care

Pharm World Sci. 2005 Apr;27(2):116-20. doi: 10.1007/s11096-004-3705-y.


Objective: The aims were to evaluate the frequency and nature of errors in medication when patients are transferred between primary and secondary care.

Method: Elderly primary health care patients (> 65 years) living in nursing homes or in their own homes with care provided by the community nursing system, had been admitted to one of two hospitals in southern Sweden, one university hospital and one local hospital. A total of 69 patient-transfers were included. Of these, 34 patients were admitted to hospital whereas 35 were discharged from hospital.

Main outcome measure: Percentage medication errors of all medications i.e. any error in the process of prescribing, dispensing, or administering a drug, and whether these had adverse consequences or not.

Results: There were 142 medication errors out of 758 transfers of medications. The patients in this study used on an average more than 10 drugs before, during and after hospital stay. On an average, there were two medication errors each time a patient was transferred between primary and secondary care. When patients were discharged from the hospital, the usage of a specific medication dispensing system constituted a significant risk for medication errors. The most common error when patients were transferred to the hospital was inadvertent withdrawal of drugs. When patients left the hospital the most common error was that drugs were erroneously added.

Conclusion: Medication errors are common when elderly patients are transferred between primary and secondary care. Improvement in documentation and transferring data about elderly patients' medications could reduce these errors. The specific medication dispensing system that has been used in order to increase safety in medication dispensing does not seem to be a good instrument to reduce the number of errors in transferring data about medication.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Aged, 80 and over
  • Female
  • Homes for the Aged / statistics & numerical data
  • Hospitals, Community / methods
  • Hospitals, Community / standards
  • Hospitals, Community / statistics & numerical data
  • Humans
  • Male
  • Medication Errors / statistics & numerical data*
  • Medication Systems, Hospital / standards
  • Medication Systems, Hospital / statistics & numerical data
  • Nursing Homes / statistics & numerical data
  • Patient Transfer / methods*
  • Patient Transfer / statistics & numerical data
  • Primary Health Care / methods*
  • Primary Health Care / standards
  • Primary Health Care / statistics & numerical data
  • Sweden