From a reactive to a proactive safety approach. Analysis of medication errors in chemotherapy using general failure...

Area of Science:

• Healthcare safety
• Medication error analysis
• Risk management in pharmaceuticals

Background:

• Medication errors (MEs) pose a significant risk in healthcare, necessitating proactive identification and mitigation strategies.
• Understanding the root causes of MEs, particularly with high-risk medications like cytotoxic drugs, is crucial for improving patient safety.
• Existing incident reporting systems may not fully capture the systemic factors contributing to MEs.

Purpose of the Study:

• To develop and evaluate a proactive tool for identifying general failure types (GFTs) in the management of cytotoxic drugs.
• To analyze the types of GFTs and active failures contributing to medication errors in a real-world setting.
• To explore how organizational weaknesses and local characteristics influence risks associated with cytotoxic drug management.

Main Methods:

• Adaptation of Reason's Tripod Delta tool to identify GFTs and active failures.
• Analysis of 60 reported medication error cases involving cytotoxic drugs from Swedish national authorities.
• Qualitative assessment of the developed tool's ability to understand contributing factors to MEs.

Main Results:

• The most frequent GFTs identified were related to defences, procedures, organisation, and design.
• Working conditions emerged as a common underlying factor in the analyzed medication errors.
• Active failures included a majority of slips and a significant proportion of mistakes.

Conclusions:

• The developed proactive tool effectively facilitates a qualitative understanding of how organizational factors contribute to medication error risks.
• Regular utilization of the GFT tool is recommended to complement existing incident reporting and risk analysis processes.
• Further development of the GFT tool into a proactive self-evaluation instrument is proposed to enhance healthcare safety.