ARV Medication Errors: Experience of a Community-Based HIV Specialty Clinic and Review of the Literature

Abstract

Objective

To describe antiretroviral (ARV) medication errors reported within a community Human Immunodeficiency Virus (HIV) clinic, identify potential strategies to prevent errors, and review the literature pertaining to ARV medication errors.

Design

Review of voluntarily reported ARV errors. Errors were classified using the National Coordinating Council for Medication Error Reporting and Prevention (NCC-MERP) Index. The clinic's medication distribution process was also analyzed.

Setting

Community-based clinic with HIV-experienced clinicians in an urban setting.

Results

Thirty-seven errors were reported over 3 years; 81.1% of these were classified as NCC-MERP category C. Most errors resulted from lapses in clinic and pharmacy systems of care (n = 21). Pharmacy and clinic prescribing errors were less (n = 11).

Conclusion

ARV medication errors were notable. Changes in drug distribution and prescribing processes may reduce future ARV medication errors.