Category: Professional Posters
Purpose: Medication errors are major global issue, adversely impacting health outcomes and patient safety. Previous studies have reported difficulties in determining the prevalence and rates of medication errors, widely due the heterogeneity in definitions, data collection, choice of denominator etc. Incident reporting systems (IRSs) are commonly used tool for medication error reporting and monitoring. The aim of this research is to analyze how medication errors/incidents are reported and detected at different stages of medication use process, to characterize the medication errors reported in terms of types of errors, severity, medication class involved etc. and to identify the causes of errors.
Methods: This is a retrospective, cross-sectional review of all medication errors reported to the incident reporting system (RL6) over a period of three years (January 2015 to December 2017). The incidence and/or rate of medication errors was calculated by dividing the number of medication errors reported to the total medication orders. The causes were classified based on the James Reason’s Accident Causation Model. According to this model, a system has a ‘sharp end’ (active failures) and a ‘blunt end’ (latent conditions). Whilst active failures are unsafe acts (e.g. slips, lapses, mistakes and violations) that originate as a part of the front-line workers, the latent failures arise mostly due to ‘error-producing conditions’ at different levels within the system (such as lack of knowledge, poor administrative support, lack of resource etc.). Medication errors were classified based types of errors such as prescribing errors, dispensing errors, administration errors or monitoring errors, further subtypes were also categorized. Medication errors reported per each hospital and the severity levels were analysed using NCCMERP severity index. Types of medication based on their pharmacological action were segregated using The Anatomical Therapeutic Chemical (ATC) Classification System that categorizes the active chemical entity based on the organ or system on which they act and their therapeutic, pharmacological and chemical properties. The study further analysed the profession of the reporter.
Results: A total of 18390 incidents w ere reported over 36 months with a mean monthly reporting rate of 510 reports (SD±260.5). Incidence of medication errors reported was found to be 0.6 medication errors/1000 medication orders. However, only 5104 reports were included in the final analysis after excluding the incomplete reports, or the reports that did not possibly allow the analysis. Prescribing errors (n= 4485 , 88% ) being the most common and monitoring errors (less than 1%) being reported the lowest. Most common types of prescribing errors reported were prescribing wrong dose (36%) followed by wrong frequency (15%). Of all the reports, majority was reported by pharmacists (90 %) followed by nurses (8%), while only < 1% were reported by the doctors. Anti-infectives for systemic use (22%) were involved in almost one fourth of the errors followed by medications used to treat neurological disorders (17 %). In terms of severity, gross majority 77% were classified as “near miss” events, no errors resulted in permanent patient harm, or patient death. Based on James Reasons accident causality model majority of the incidents reported were classified as Active Failures (90%) that includes Mistakes (59%), Slips (15%), Lapse (12%), Violations (4%).
Conclusion: Medication errors are common, with prescribing errors being the most common type of error reported. Therefore, preventive strategies to minimize medication errors should aim at improving prescribing competency. Low contribution to reporting from non pharmacy profession requires an in depth investigation, an inquiry using qualitative research design underpinning theoretic framework will be most appropriate at this stage. Furthermore, to compare the data with international data, a standardized approach to quantifying medication errors is warranted.