Identifying medication error chains from critical incident reports: a new analytic approach

Area of Science:

• Patient Safety
• Healthcare Quality Improvement
• Medication Management

Background:

• Traditional medication error research often examines single points in the medication use process.
• A process-oriented approach is needed to understand how errors propagate.

Purpose of the Study:

• To analyze medication incidents using a process-oriented approach, focusing on medication error chains.
• To identify the frequency and characteristics of medication error chains in a hospital setting.

Main Methods:

• Analysis of 1,591 reported medication errors from 2009-2012 in a 900-bed Swiss teaching hospital.
• Categorization using the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) Index and WHO Classification for Patient Safety.
• Allocation of incidents to stages of the hospital medication use process to identify error chains.

Main Results:

• 74.2% of medication errors formed chains across two or more stages.
• Only 25.8% of errors were detected before propagating.
• The most common error chain involved preparation through administration (45.2%).
• "Non-consideration of documentation/prescribing" during preparation frequently led to "wrong dose" errors during administration.

Conclusions:

• Medication error chains offer valuable insights into error propagation.
• Interventions should focus on interrupting these chains to enhance patient safety.
• Existing and new safety barriers require enhancement to break error chains effectively.