[Tracing the map of medication errors outside the hospital environment in the Madrid Community]

Preparation of a map of medication errors reported by health professionals outside hospitals within the framework of Medication Errors Reporting for the Community of Madrid during the period 2008-2009.

Retrospective observational study.

Notification database of medication errors in the Community of Madrid.

Notifications sent to the web page: Safe Use of Medicines and Health Products of the Community of Madrid.

Information on the originator of the report, date of incident, shift, type of error and causes, outcome, patient characteristics, stage, place where it was produced and detected, if the medication was administered, lot number, expiry date and the general nature of the drug and a brief description of the incident.

There were 5470 medication errors analysed, of which 3412 came from outside hospitals (62%), occurring mainly in the prescription stage (56.92%) and being more reported pharmacists. No harm was done in 92.9% of cases, but there was harm in 4.8% and in 2.3% there was an error that could not be followed up.

The centralization of information has led to the confirmation that the prescription is a vulnerable point in the chain of drug therapy. Cleaning up prescription databases, preventing the marketing of commercial presentations that give rise to confusion, enhanced information to professionals and patients, and establishing standardised procedures, and avoiding the use of ambiguous prescriptions, illegible, or abbreviations, are useful strategies to try to minimise these errors.