Antiretroviral and Medication Errors in Hospitalized HIV-Positive Patients

Ann Pharmacother. 2014 Aug;48(8):998-1010. doi: 10.1177/1060028014534195. Epub 2014 May 8.


Objective: To summarize the literature regarding antiretroviral and other medication errors in hospitalized HIV-positive patients and to discuss potential interventions and solutions that have been studied to minimize drug error.

Data sources: A systematic search of MEDLINE, PubMed, and EMBASE (2000-April 2014) was conducted. Search terms included HIV/AIDS, HAART, hospitalization, patient admission, inpatient, patient transfer, medication error, inappropriate prescribing, drug interaction, drug omission, drug toxicity, and contraindication.

Study selection and data extraction: English-language research articles, case reports, conference abstracts, and letters to the editor were reviewed.

Data synthesis: A high overall medication error rate was reported in HIV-positive inpatients. Errors occurred mainly at the time of prescribing on admission but were also detected throughout hospitalization and at discharge. Errors in the antiretroviral regimen, dosing, scheduling, and drug-drug and drug-food interactions were the most common. The most successful interventions involved a clinical pharmacist, who specializes in infectious diseases and/or HIV, completing medication reconciliation on admission, reviewing orders daily, and screening for errors at discharge.

Conclusions: Although studies varied greatly in methodology, overall, a large number of medication errors occurred in this patient population. This underscores the important role the pharmacist has in optimizing care to hospitalized HIV-positive patients and provides further insights into the types of medication errors that occur and proposed solutions to reduce these errors. Because medication errors are multifactorial, ongoing initiatives to improve the quality of medication reconciliation processes, educate the health care team on antiretroviral medications, and improve the drug distribution system are required.

Keywords: HIV/AIDS; antiretrovirals; dosing; drug interactions; drug safety; medication errors; medication safety.

Publication types

  • Review