Medication-related incidents at 19 hospitals: A retrospective register study using incident reports

Area of Science:

• Patient Safety
• Medication Management
• Healthcare Quality Improvement

Background:

• Medication incidents pose a significant risk to patient safety.
• Understanding the patterns and causes of these errors is crucial for developing effective prevention strategies.

Purpose of the Study:

• To investigate the timing and types of medication incidents.
• To assess patient harm resulting from medication errors.
• To explore healthcare professionals' perceptions of incident causes and reporting patterns.

Main Methods:

• A descriptive, multicentre register study analyzing 775 medication incident reports from 19 Swedish hospitals (2016-2017).
• Statistical analysis of incident classification and consequences.
• Content analysis of perceived causes for a subset of 128 reports.

Main Results:

• Medication incidents were equally common in prescribing and administering phases.
• Wrong dose was the most frequent error, followed by missed dose and lack of prescription.
• Most incidents did not result in patient harm, though administration errors were more likely to reach patients.
• Shortcomings in knowledge, skills, and abilities, along with workload, were the most perceived causes.
• Nurses were the primary reporters of medication incidents.

Conclusions:

• Medication errors are prevalent in both prescribing and administration, with 'wrong dose' being the most common type.
• While most incidents have minimal patient impact, system-level factors like knowledge gaps and workload contribute significantly.
• Targeted interventions focusing on improving knowledge, skills, and managing workload are essential for reducing medication errors.