Lessons learned: using adverse incident reports to investigate the characteristics and causes of prescribing errors

Abstract

IntroductionPrescribing errors are a principal cause of preventable harm in healthcare. This study aims to establish a systematic approach to analysing prescribing-related adverse incident reports, in order to elucidate the characteristics and contributing factors of common prescribing errors and target multifaceted quality improvement initiatives.MethodsAll prescribing-related adverse incident reports submitted across one NHS board over 12 months were selected. Incidents involving commonly implicated drugs (involved in ≥10 incidents) underwent analysis to establish likely underlying causes using Reason’s Model of Accident Causation.Results330 prescribing-related adverse incident reports were identified. Commonly implicated drugs were insulin (10% of incidents), gentamicin (7%), co-amoxiclav (5%) and amoxicillin (5%). The most prevalent error types were prescribing amoxicillin when contraindicated due to allergy (5%); prescribing co-amoxiclav when contraindicated due to allergy (5%); prescribing the incorrect type of insulin (3%); and omitting to prescribe insulin (3%). Error-producing factors were identified in 86% of incidents involving commonly implicated drugs. 53% of incidents involved error-producing factors related to the working environment; 38% involved factors related to the healthcare team; and 37% involved factors related to the prescriber.DiscussionThis study establishes that systematic analysis of adverse incident reports can efficiently identify the characteristics and contributing factors of common prescribing errors, in a manner useful for targeting quality improvement. Furthermore, this study produced a number of salient findings. First, a narrow range of drugs were implicated in the majority of incidents. Second, a small number of error types were highly recurrent. Lastly, a range of contributing factors were evident, with those related to the working environment contributing to the majority of prescribing errors analysed.

Identifying high‐risk medications and error types in Danish patient safety database using disproportionality analysis

“…The present study did not find signals for commonly mentioned high‐risk medicines such as gentamicin, digoxin and methotrexate 26 . Gentamicin was previously found to be associated with MEs in a study on ME in children 17 and in a study on prescribing MEs in a general population 30 . This discrepancy may be explained by the differences in the investigated populations (adult, pediatric and general).…”

“…26 Gentamicin was previously found to be associated with MEs in a study on ME in children 17 and in a study on prescribing MEs in a general population. 30 This discrepancy may be explained by the differences in the investigated populations (adult, pediatric and general).…”

“…9,19,27,28 Moreover, we found similarities regarding the drugs and the identified stages in the medication process. Harmful MEs with warfarin and morphine were associated with prescribing, 29,30 insulinswith administering of the wrong dose, 31 while fentanyl was linked to errors during administering. 32 The present study also adds some nuances to the identified ME situations.…”

When I use a word . . . Naming medicines—mixtures and co-names

“…As an example of the problems that can occur, in a study of 330 reports of adverse incidents related to prescriptions the drugs most commonly involved were insulin (10% of incidents), gentamicin (7%), co-amoxiclav (5%), and amoxicillin (5%). In 15 cases co-amoxiclav was given to people with penicillin allergy (4.5% of the total) 14. If you don’t know that co-amoxiclav contains amoxicillin, this is an error that you can easily make, with potentially fatal consequences.…”

Implementation of an Automated Dispensing Cabinet System and Its Impact on Drug Administration: Longitudinal Study (Preprint)

“…According to an investigation by Taiwan's Ministry of Health and Welfare, from 2014 to 2019, there were more than 20,000 adverse drug events (ADEs) every year. Some studies found that many serious medical errors-which cause or have the potential to cause damage or injury-are drug prescription or administration errors [1][2][3][4]. Different studies have used interventions to reduce these errors.…”