Category: Professional Posters
Purpose: Medication errors (ME)are inevitable, recognised one of the major cause of morbidity and mortality among hospitalised patients. Previous research around medication management has focussed on either hospitalised patients, long-term care facilities or in community, however little is known about medication management process in home healthcare services (HHC). HHCs in Qatar is relatively new, to stimulate development of interventions to improve medication use among such vulnerable population, information is needed regarding the frequency, and causes of ME occurring in these facilities. The current study aims to determine the frequency, type, and causes of ME reported among home healthcare patients in Qatar.
Methods: This was a retrospective, cross-sectional study of all ME reported to the HMC reporting system over a period of three years (January 2015 to December 2017). Medication safety officer collected and extracted the data and further assessed it for appropriateness and quality. A standardised tool to assess the quality was developed by the research team and piloted. Incidence of medication errors were calculated as, the number of medication errors reported for HHC patients as numerator divided by the total number of medication errors reported to the incident monitoring system as denominator. To compare the findings with international data we have standardised the results to 1000 patients. ME were further classified to The National Coordinating Council for Medication Error Reporting and Prevention for severity and classification. James Reason Model of Accident Causation a theoretical model was used to describe the contributory factors associated with errors in these patients. A data collection tool was developed from previously published literature aroung medication errors. Data analysis was descriptive in nature. Microsoft Excel, SPSS® version 20 was used for data management and data analysis
Results: A total of 512/18200 (2.81%) ME were reported from home Hamad Medical Corporations healthcare services. However, after excluding the duplicates, records not related to ME, incomplete entries and ME errors without proper justifications, only 181 unique entries were selected to the final review and analysis. Majority of the errors were administration errors (70.2%) that occurred while administration of the medication either by the patient, caregiver or other healthcare professional. Most common cause of administration errors reported were due to non compliance to the physicians order (29.2%) followed by administering a wrong drug or dose (20.8%). Medication errors commonly happened in adult population (95%), while just below 5% were reported among pediatric patients. Medication class most commonly involved in medication errors were anti-thrombotic agents (20%) followed by systemic hormones (13.3%), drugs acting on cardiovascular system (7.7%). We classified causes into Active failure (80%), Error Provoking conditions (19.3%) and Latent failures (0.6%). Of active failures, mistakes (37%) and violations (22.1% )were more frequently occurring than slips (9.4%) or lapses (11.6%). Majority of the incidents were categorized as those cause harm or caused minor harm that just required monitoring (53%).
Conclusion: The current study targeting vulnerable population such as home healthcare care is first of its kind in the region. Medication error reporting at home healthcare center is relatively low, and the existing ones are of poor quality. Future interventions in terms of education or training targeting healthcare professionals and caregivers at home healthcare services in Qatar is warranted. Considering the diverse, culture and educational background of healthcare professions in Qatar, studies should also focus on exploring the reporting of severe medication errors that actually caused harm.