Describing and Quantifying Wrong-Patient Medication Errors Through a Study of Incident Reports

Area of Science:

• Medical Safety
• Clinical Risk Management
• Health Informatics

Background:

• Wrong-patient errors in medication administration pose a significant risk to patient safety.
• Existing definitions may not fully capture the complexities of these errors.
• Incident reports are valuable for understanding error mechanisms.

Purpose of the Study:

• To develop a new, comprehensive definition of wrong-patient errors in medication administration.
• To analyze incident reports to identify the root causes and contributing factors of these errors.

Main Methods:

• Analysis of 4337 incident reports (IRs) from a Japanese university hospital (2015-2016).
• Evaluation of 30 wrong-patient medication errors by four independent evaluators.
• Investigated patient-drug or patient-CPOE screen mismatches and contributory factors.

Main Results:

• Wrong-patient medication errors constituted 2% (30/4337) of all medication errors.
• Errors stemmed from patient-drug/CPOE screen mismatches due to incorrect selections.
• Key contributing factors included similar patient/drug names, proximity on lists, and insufficient confirmation.

Conclusions:

• Proposed definition: Wrong-patient medication errors involve choosing a wrong target and insufficient confirmation.
• This definition provides a framework for understanding and preventing these critical errors.
• Further research will explore applying this definition to other types of wrong-patient errors.