[Medication errors in a tertiary hospital with three different drug delivery systems]

Area of Science:

• Pharmacology and Pharmacy Practice
• Patient Safety Research
• Healthcare Quality Improvement

Background:

• Medication errors pose a significant risk to patient safety in healthcare settings.
• Understanding the types and rates of medication errors across different delivery systems is crucial for targeted interventions.
• Previous studies have indicated variability in error rates depending on medication management processes.

Purpose of the Study:

• To quantify the overall proportion of medication errors in a tertiary hospital.
• To compare medication error rates across distinct medication delivery systems.
• To identify common types of medication errors and associated risk factors.

Main Methods:

• Direct observation of 2,242 medication administration opportunities by trained observers.
• Categorization of medication delivery systems into: stock in ward, unit dose with electronic prescription, and unit dose with computerized transcription.
• Statistical analysis using logistic regression to identify factors associated with medication errors.

Main Results:

• A medication error rate of 7.2% was observed, with 4.4% reaching the patient.
• Error rates varied by delivery system: 9.5% for stock in ward, 7.8% for electronic prescription, and 4.7% for computerized transcription.
• The administration phase accounted for 58.4% of errors, with omitted doses being the most common (31.7%).

Conclusions:

• Medication errors occur in approximately 1 in 14 opportunities, emphasizing the need for vigilance.
• Different medication delivery systems demonstrate significantly different medication error rates.
• The findings underscore the importance of optimizing medication delivery systems to enhance patient safety.