[Medication safety in the home care setting: error-prone process steps]

Area of Science:

• Health Sciences
• Patient Safety
• Pharmaceutical Care

Context:

• Homecare settings face significant challenges in medication management.
• An estimated 30% of homecare patients experience potential medication errors.
• Understanding drug-related problems is crucial for improving patient outcomes.

Purpose:

• To identify error-prone steps in the medication use process within a Swiss homecare organization.
• To analyze the complexity and potential risks associated with medication administration in homecare.
• To provide data for targeted interventions to reduce medication errors.

Summary:

• Direct observation and analysis of 10% of prescriptions were conducted in a homecare organization serving 1854 patients annually.
• A combination of critical incident reporting, nurse surveys, and failure mode and effects analysis was used.
• The medication use process involves 20 steps, with patients averaging 7.5 drugs daily. 74% of 84 reported errors occurred during drug preparation.

Impact:

• Identified communication with physicians, patient interruptions, and uncommunicated regimen changes as critical process steps.
• Highlights the need for improved protocols in drug preparation and administration within homecare.
• Findings can inform strategies to enhance medication safety and reduce adverse drug events in homecare patients.