Causes and types of voluntarily reported unintentional medication discrepancies in care transitions: a...

Medication incident reporting systems enable healthcare professionals to report incidents and their analysis may help prevent reoccurrences. While previous research has primarily focused on medication errors in general, incidents involving unintentional medication discrepancies remain unexplored.

Therefore, this study aimed to identify the causes of voluntarily reported medication incidents describing unintentional medication discrepancies occurring in care transitions. The secondary objective was to characterise the reported medication incidents regarding type of incident, medication involved, whether the incident reached the patient, and the transfer moment involved.

This cross-sectional study used data from the National Medication Incident Reporting database of the Dutch Institute for Rational Use of Medicine. This database contains medication incidents, mainly reported by healthcare professionals in hospitals. Incidents were included if they described an unintentional medication discrepancy in a care transition. The primary outcome was the cause of the reported incident independently determined by two researchers using the Prevention and Recovery Information System for Monitoring and Analysis model (PRISMA-Medical). Secondary outcomes were the incident type (e.g., omissions or dose discrepancies), the medication involved, whether the incident reached the patient, and the transfer moment. Descriptive statistics were used for data-analysis (frequencies and percentages).

A total of 32,261 incidents were reported in the study period, of which 992 (3.1%) met the inclusion criteria. Most incidents were attributed to human factors (n = 932; 94.0%), with verification errors (n = 492; 49.6%) and intervention errors (n = 246; 24.8%) being the most common. Organisational and technical causes accounted for 40 (4.0%) and 20 (2.0%) incidents, respectively. Omissions represented the most frequent type of discrepancies (n = 354; 36.2% of 978 reported discrepancy types), and cardiovascular medication was most frequently involved (n = 339; 24.9% of 1,360 reported medications). Among incidents with available data (n = 599), 444 (74.1%) reached the patient. Most incidents occurred at hospital admission (n = 679; 71.4% of 951 incidents with data available) and discharge (n = 229; 24.1%).

Most reported incidents in care transitions were attributable to human error. These findings highlight the need for better preventive measures, e.g. patient-centred medication reconciliation to enhance patient safety.