Patient safety incidents involving transdermal opioids: data from the Danish Patient Safety Database

Olesen, Anne Estrup; Henriksen, Jakob Nørgaard; Nielsen, Lars Peter; Knudsen, Pia; Poulsen, Birgitte Klindt

doi:10.1007/s11096-020-01057-6

Cited by 7 publications

(6 citation statements)

References 21 publications

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“…The annual reports on patient safety incidents from the Danish Patient Safety Authority (DPSA) reveal that medication‐related events are the largest incident category in the database for all healthcare sectors, accounting for 25.6% in public hospitals and 66.4% in community healthcare services 7 . However, our knowledge on these incidents mainly relies on general level information provided by the DPSA's annual reports, a few studies on specific drugs, 11,12 and studies in specific populations, like hospitalized children 13 . Exploring data on medication incidents from across the entire Danish healthcare system may provide an evidence‐based background for further medication safety initiatives.…”

Section: Introductionmentioning

confidence: 99%

Medication incidents and medication errors in Danish healthcare: A descriptive study based on medication incident reports from the Danish Patient Safety Database, 2014–2018

Tchijevitch

Hallas

Bogh

et al. 2023

Basic Clin Pharma Tox

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In Denmark, reporting of safety incidents to the nationwide Danish Patient Safety Database (DPSD) is mandatory. Medication incident reports constitute the largest category of safety reports. We aimed to provide numbers and characteristics of medication incidents and MEs reported to DPSD focusing on medication, their severity and the trends therein. This is a cross-sectional study of medication incident reports for individuals ≥18, submitted to DPSD in 2014-2018. We performed analyses on the (1) medication incident and (2) ME levels. Out of 479 814 incident reports, 61.18% (n = 293 536) were related to individuals ≥70 and 44.6% (n = 213 974) to nursing homes. Most of the events were harmless (70.87%, n = 340 047) and 0.8% (n = 3859) had caused severe harm or death. ME-analysis (n = 444 555) revealed that paracetamol and furosemide were the most frequently reported drugs. The most common drugs for severe and fatal MEs were warfarin, methotrexate, potassium chloride, paracetamol and morphine. When the reporting ratio for all MEs and harmful MEs was considered, other drugs than the most frequently reported ones were found to be associated with harm. We found a large proportion of harmless medication incident reports and reports from community healthcare services and identified high-risk medicines associated with harm.

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Section: Introductionmentioning

confidence: 99%

Medication incidents and medication errors in Danish healthcare: A descriptive study based on medication incident reports from the Danish Patient Safety Database, 2014–2018

Tchijevitch

Hallas

Bogh

et al. 2023

Basic Clin Pharma Tox

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“…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. For example, we identified many antipsychotic drugs reported as "medicine not taken"; this area may be worth further examination.…”

Section: Discussionmentioning

confidence: 64%

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

Tchijevitch,

Birkeland,

Bogh

et al. 2024

Pharmacoepidemiology and Drug

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BackgroundMedication error (ME) surveillance in Danish healthcare relies on the mandatory national incident reporting system, the Danish Patient Safety Database (DPSD). Individual case reviews and descriptive statistics with frequency counts are the most often used approaches when analyzing MEs in incident reporting systems, including the DPSD. However, incident reporting systems often generate a large number of reports and may suffer from underreporting; consequently, additional approaches are needed to overcome these challenges. Disproportionality analysis (DPA) is a statistical tool used for signal detection of adverse drug reactions in pharmacovigilance reports, but the evidence for using DPA on ME analysis in safety reporting systems is limited.ObjectivesWe aimed to test the feasibility of DPA by analysing harmful MEs reported to DPSD 2014–2018.MethodsWe utilized proportional reporting ratios (PRR) to identify signals of diproportionality.ResultsWe identified well‐known high‐risk medicines, including anticoagulants, opioids, insulins, antiepileptic, and antipsychotic drugs, and their association with several ME types and stages in a medication process.ConclusionDPA might be suggested as an additional tool for screening MEs and identifying priority areas for further investigation in safety reporting systems.

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“…Through the network of sentinel pharmacies, we are able to detect, notify, analyze, and prevent several MEs detected during the dispensing process, as described in the currently available literature [5,7,[18][19][20][21][22][23][24]. Complementarily, MEs detected in the hospital and primary care settings primarily affect the processes of the therapeutic chain related to prescription and administration [25][26][27].…”

Section: Discussionmentioning

confidence: 99%

Detection and Prevention of Medication Errors by the Network of Sentinel Pharmacies in a Southern European Region

Jambrina

Santomà

Rocher

et al. 2022

JCM

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A medication error (ME) is a drug-related problem that has been recognized as a common and serious threat to patient safety. The aim of this study was to detect and analyze ME reports occurring throughout the therapeutic process through the community’s pharmacies in order to improve the efficacy and safety of medications and contribute to the prevention of future MEs. This was a three-year descriptive, observational, and prospective study to detect and analyze the different MEs reported by the Catalan sentinel pharmacies network (Catalan SePhaNet). In total, 1394 notifications of MEs were reported (an incidence rate of 737.34 cases/100,000 inhabitants). MEs were detected more frequently in primary care centers. Most of the MEs reported were caused by an incorrect, incomplete, illegible, or verbal medical prescription (41.3%). Of the global notifications detected, 71.9% did not reach the patient (categories A and B). The drugs most frequently implicated in the reported ME cases were beta-lactam antibiotics. In 6.0% of the cases, the ME caused injury to the patient (categories E and F). In 72.0% of the global notifications, a pharmacist’s intervention avoided the ME. The importance of a community pharmacy and the role of a pharmacist were demonstrated in aspects related to patient and drug safety.

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Patient safety incidents involving transdermal opioids: data from the Danish Patient Safety Database

Cited by 7 publications

References 21 publications

Medication incidents and medication errors in Danish healthcare: A descriptive study based on medication incident reports from the Danish Patient Safety Database, 2014–2018

Medication incidents and medication errors in Danish healthcare: A descriptive study based on medication incident reports from the Danish Patient Safety Database, 2014–2018

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

Detection and Prevention of Medication Errors by the Network of Sentinel Pharmacies in a Southern European Region

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