Out-of-hospital medication errors: a 6-year analysis of the national poison data system

Pharmacoepidemiol Drug Saf. 2009 Nov;18(11):1080-5. doi: 10.1002/pds.1823.


Purpose: Previous research and reporting has focused on the incidence and prevention of medication errors in the hospital setting; however, no previous study has reported the frequencies, characteristics and outcomes of out-of-hospital medication (OHME) errors.

Method: Data from the National Poison Data System (NPDS) was collected for 2000-2005 and information regarding out-of-hospital medication errors reported to Poison Control Centers (PCC) was collected by a trained investigator.

Results: From 2000-2005 there were 1,166,116 OHME reported to PCC. Of these patients, 88,451 (7.5%) received medical evaluation by a healthcare provided and 229 (0.01%) deaths reported. The most common drug classes involved included cough/cold medications, analgesics, cardiovascular agents, antihistamines, antidepressants and antimicrobial agents. The most common error reported in both children and adults was taking or giving medication twice.

Conclusions: OHME occur frequently and the NPDS may be a useful resource for data collection and evaluation in this previously overlooked population. The majority of OHME reported did not result in any significant morbidity or mortality and were managed at home without need for healthcare referrral. Further study of OHME is needed, and in particular whether healthcare professionals can target educational instruction to patients so as to effectively reduce the frequency of the most common or injurious errors.

MeSH terms

  • Adverse Drug Reaction Reporting Systems
  • Ambulatory Care
  • Databases, Factual
  • Drug Overdose
  • Humans
  • Medication Errors* / statistics & numerical data
  • Medication Errors* / trends
  • Pharmaceutical Preparations / administration & dosage*
  • Poison Control Centers*
  • Poisoning / epidemiology*
  • Poisoning / etiology
  • United States


  • Pharmaceutical Preparations