Risk Analysis of Errors in Prescribing, Dispensing and Administering Medications within a District Hospital

Abstract

Aim: To investigate errors in prescribing, dispensing and administering medications, determine the origin of the error and analyse the risks according to established risk-rating matrices. Method: Errors detected by pharmacists were recorded and combined with errors recorded by nurses and doctors. Errors were classified by type of event, source of report and professional group responsible for the occurrence. Errors were evaluated against two risk-rating matrices developed by Queensland Health and Standards Australia. Results: Reported errors occurred at the rate of 1.8% of drugs prescribed over the period from admission to discharge. There were no dispensing errors reported during the study period. Nurses reported 150 incidents and pharmacists detected 275. In the majority of cases it was possible to identify the node in the medication-use process that was associated with the error (35% administering and 53% prescribing) but this was not possible in 12% of cases. The two largest categories of errors were incorrect dose prescribed (29%) and dose not recorded as given (28%). There was a marked difference in risk profile between the two risk-rating matrices. Conclusion: The majority of errors were due to performance lapses or lack of knowledge. The difference in risk profiles suggests that hospitals should adopt a uniform risk-rating matrix for benchmarking purposes. To avoid underestimates of hospital error rates, a reporting system that can interface with pharmacy information-management systems needs to be developed . INTRODUCTIONPharmacists have traditionally collected data on interventions made during clinical ward rounds or when dispensing prescriptions. This data collection is sporadic, or limited to occasions that seem particularly interesting or significant. The limited scope of collection is mainly due to workload issues or a perceived lack of opportunity to influence the behaviour of those who prescribe and administer drugs. It appears that many pharmacy departments do not report their intervention data to the hospital executive and therefore senior managers are not aware of the extent to which pharmacists reduce the risk of misadventure to patients.This study was conducted at Queen Elizabeth II Jubilee Hospital, Queensland-a 168-bed district hospital providing gynaecology, orthopaedic, urology, geriatric rehabilitation, general surgery, general medicine, intensive care, and accident and emergency services. The hospital has a high turnover of doctors, many of whom are overseas-trained. As a large proportion of these staff arrive outside of normal staff changeover times when there is no organised training and orientation, there is a great need for scrutiny of their prescribing practices.

Incidence, type and causes of dispensing errors: a review of the literature

“…Various research methods were used to investigate dispensing errors, including self‐completed standardized incident forms, observation, postal surveys, simulation, interviews, case‐note review and focus groups 3,14–72 . In some research papers mixed methods were used to determine the incidence and causes of dispensing errors 15,30,43,65 Table 3 3,14–35,37–62,64–71 . summarizes the research methods employed by the identified research papers.…”

“…Forty‐five reviewed papers reported the dispensing error rate in community and/or hospital pharmacy (Tables 7 and 8). 14,15,17,19,21,24–28,30,32, 3,33–35,38,39,43–47,49–57,59–72 However, only 18% ( n = 8) of these papers clearly defined the calculation of dispensing‐error rate 15,28,30,52,56,59,61,62 . In the remaining 37 papers, the dispensing‐error rate calculation (numerator and denominator) was elucidated from the data presented in the papers.…”

“…Three reviewed papers investigated the incidence of unprevented dispensing incidents in hospital pharmacies 67–69 . The reported rate of unprevented dispensing incidents ranged from 0 to 1.6% (Table 8).…”

“…Reviewed papers detailing research undertaken in Australian hospitals did not identify the types of dispensing errors 67–69 …”

Exploring the causes of junior doctors' prescribing mistakes: a qualitative study

“…Previous studies that have investigated the causes of prescribing errors report lack of drug knowledge , the working environment , poor communication , complex patients (including polypharmacy ) and the low priority attached to prescribing as contributing to prescribing errors. A systematic review we conducted into the causes of prescribing errors found that errors were multifactorial and lack of knowledge was only one causal factor amongst many .…”