Wrong-patient incidents during medication administrations

Area of Science:

• Patient safety
• Medication administration errors
• Healthcare quality improvement

Background:

• Despite prioritizing patient identification for safety, misidentifications and wrong-patient incidents remain prevalent.
• Understanding the contributing factors to wrong-patient medication errors is essential for developing effective prevention strategies.

Purpose of the Study:

• To identify factors contributing to medication being administered to the wrong patient.
• To analyze how patient identification is documented in wrong-patient incident reports.

Main Methods:

• A descriptive content analysis of 1,012 medication administration incident reports from two Finnish hospitals (2013-2014).
• Focus on 103 incidents specifically involving wrong-patient medication administration.

Main Results:

• Wrong-patient incidents result from nurse-related factors (e.g., fatigue, lack of skills) and system-related factors (e.g., rushing, heavy workloads).
• Patient identification processes were not described in 77% of wrong-patient incident reports, indicating a significant documentation gap.

Conclusions:

• Enhanced training in correct patient identification procedures is necessary to reduce wrong-patient medication errors.
• Addressing system factors like workload and improving communication are vital.
• Implementing active patient identification, double-checking, and nurse involvement can enhance safety and risk awareness.