Identifying medication error chains from critical incident reports: A new analytic approach

Abstract

Research into the distribution of medication errors usually focuses on isolated stages within the medication use process. Our study aimed to provide a novel process-oriented approach to medication incident analysis focusing on medication error chains. Our study was conducted across a 900-bed teaching hospital in Switzerland. All reported 1,591 medication errors 2009-2012 were categorized using the Medication Error Index NCC MERP and the WHO Classification for Patient Safety Methodology. In order to identify medication error chains, each reported medication incident was allocated to the relevant stage of the hospital medication use process. Only 25.8% of the reported medication errors were detected before they propagated through the medication use process. The majority of medication errors (74.2%) formed an error chain encompassing two or more stages. The most frequent error chain comprised preparation up to and including medication administration (45.2%). "Non-consideration of documentation/prescribing" during the drug preparation was the most frequent contributor for "wrong dose" during the administration of medication. Medication error chains provide important insights for detecting and stopping medication errors before they reach the patient. Existing and new safety barriers need to be extended to interrupt error chains and to improve patient safety.

A combined intervention to reduce interruptions during medication preparation and double-checking: a pilot-study evaluating the impact of staff training and safety vests

“…However, a main focus should be on interruptions during medication preparation and double‐checking of prepared medications. These are the final stages in the medication process prior to administration, with few safeguards against errors reaching the patient (Huckels‐Baumgart & Manser ). Most studies considering interruptions during the medication process concentrate on medication administration (Biron et al .…”

Medication errors in a cohort of pediatric patients with acute lymphoblastic leukemia on remission induction therapy in a tertiary care hospital in Mexico

“…This may be due to the fact that our medication process has multiple transcription stages and might be prioritizing the correct transmission of the prescribed dose rather than verifying its adequateness for the patient, thus facilitating the propagation of MEs. Other prospective studies with systematic safety and medication surveillance systems intercepted between 2% and 15.4% of prescribing errors . Therefore, it is necessary to redesign our medication system in order for it to be fail‐safe.…”

“…The establishment of general measures for safe medication, such as personnel training programs, dose calculation verification by a second person (probably a nurse), body weight updating and application of standard criteria in body surface area rounding, as well as specific measures such as assistance of a clinical pharmacist , and technological assistance systems are actions that have been shown to reduce the frequency of MEs, and have the potential to increase patient safety…”

Assessing the quality of medication documentation: development and feasibility of the MediDocQ instrument for retrospective chart review in the hospital setting

“…Medication-related adverse events (MRAE) are among the most common healthcare-related adverse events 9–12. The medication process13 frequently involves several interfaces between different care professionals within or across hospital units, necessitating clear and transparent documentation. Prescription orders and medication administration documented in patient records allow nurses and physicians, working across time and locations, to access relevant information at any point in time 7.…”