A review of medication incidents reported to the National Reporting and Learning System in England and Wales over 6 years (2005–2010)

Abstract

was undertaken. The 526 186 medication incident reports represented 9.68% of all patient safety incidents. Medication incidents from acute general hospitals (394 951) represented 75% of reports. There were relatively smaller numbers of medication incident reports (44 952) from primary care, representing 8.5% of the total. Of 86 821 (16%) medication incidents reporting actual patient harm, 822 (0.9%) resulted in death or severe harm. The incidents involving medicine administration (263 228; 50%) and prescribing (97 097; 18%) were the process steps with the largest number of reports. Omitted and delayed medicine (82 028; 16%) and wrong dose (80 170; 15%) represented the largest error categories. Thirteen medicines or therapeutic groups accounted for 377 (46%) of the incidents with outcomes of death or severe harm. The National Patient Safety Agency (NPSA) has issued guidance to help minimize incidents with many of these medicines. Many recent incidents could have been prevented if the NPSA guidance had been better implemented. It is recommended that healthcare organizations in all sectors establish an effective infrastructure to oversee and promote safe medication practice, including an annual medication safety report. In the future, preventable harms from medication incidents can be further minimized by; the continued use of the NRLS to identify and prioritize important actions to improve medication safety, a central organization continuing to issue medication safety guidance to the service and better methods to ensure that the National Health Service has implemented this guidance.

Safety Incidents in the Primary Care Office Setting

“…42 High numbers of reports describing harmful medication incidents were expected, as they are often harmful and widely cited as the most common medical errors. 1,[43][44][45][46] In addition, medication incidents in pediatrics may be #3 times more common than in adults. 43,47 Most medications are prescribed off license and can require complex dose calculations.…”

Medication Errors and Reporting in Pediatrics

“…İngiltere'de 5437999 olay bildiriminin incelendiği bir çalışmada, ilaçla ilgili olayların %9,6 ile ikinci sırada olduğu gösterilmiştir (10) . İspanya'da yoğun bakım ünitelerinde yapılan bir gözlem çalışma-sında da hastaların %58'inin bir ya da daha fazla oranda ilaç hatasına maruz kaldığı tespit edilmiştir (11) .…”

Reporting of medication errors by pediatric nurses

“…In Manal and Hannan's study [7] conducted with clinical and intensive care nurses, 76.5% and 67.6% of the nurses respectively did not report medication errors because they were scared of nurse managers, and 54.8% and 46.5% of them respectively did not report medication errors for fear of receiving disciplinary punishment or losing their job. Cousins, Gerrett and Warner [30] conducted a study on the reporting of medication-related events and determined that reporting increased by about 50% each year between 2005 and 2010. This is probably because not only has employees' awareness of patient safety and error reporting increased but also culture-making efforts on this issue have been made.…”