Self report may lead to underestimation of ‘wrong dose’ medication errors

Kiekkas, Panagiotis; Αρέθα, Διαμάντω; Karga, Mary; Καρανικόλας, Μενέλαος

doi:10.1111/j.1365-2125.2009.03530.x

Cited by 6 publications

(6 citation statements)

References 9 publications

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“…In particular, the incidence of wrong-dose errors could be underestimated in voluntary selfreport studies, owing to both workers' difficulties in becoming aware of such errors and social desirability bias or self-esteem bias (because wrong-dose errors are primarily attributed to individual deficiencies, participants may tend to underreport them). 29 Even in this case, it is important that wrong dose was among the 3 most common error types in another 2 ICU personnel self-report studies, 25,30 thus indicating a similar trend between the direct observation and voluntary self-report methods.…”

Section: Discussionmentioning

confidence: 73%

Medication Errors in Critically Ill Adults: A Review of Direct Observation Evidence

Kiekkas¹,

Karga²,

Lemonidou³

et al. 2010

American Journal of Critical Care

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Objective To systematically review clinical evidence gathered by direct observation of medication errors in adult patients in intensive care units. Methods Articles published between 1985 and 2008 in Englishlanguage journals indexed by the Cumulative Index for Nursing and Allied Health Literature and PUBMED were searched for studies on medication errors made by intensive care unit nurses. Studies in which errors were detected via direct observation were included. Results Six studies met the inclusion criteria, and error incidence varied considerably among them. Wrong dose, wrong administration time and rate, and dose omission were the most common errors. Antibiotics, electrolytes, and cardiovascular drugs were commonly associated with errors, but the evidence about factors contributing to errors was inconclusive. Increased monitoring was the most common consequence of medication errors, whereas life-threatening and fatal adverse events were rare. Conclusions Identification of patterns and characteristics of medication errors can guide preventive interventions. Factors contributing to errors, as well as drugs and error types associated with severe adverse events, deserve further investigation.

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Section: Discussionmentioning

confidence: 73%

Medication Errors in Critically Ill Adults: A Review of Direct Observation Evidence

Kiekkas¹,

Karga²,

Lemonidou³

et al. 2010

American Journal of Critical Care

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“…The study only included incidents reported to the hospital’s voluntary reporting system. It has been suggested that wrong dose errors are less likely to be self-reported than some other types of errors 29. This may be because wrong dose errors may be undetected, particularly administration errors, and also the perception that they are more likely to be seen as the fault of individuals more than other error types that can be attributed to organisation factors such as workload, training or equipment failure.…”

Section: Discussionmentioning

confidence: 99%

Magnitude of error: a review of wrong dose medication incidents reported to a UK hospital voluntary incident reporting system

Cavell

Mandaliya

2019

Eur J Hosp Pharm

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ObjectivesOur aim was to review medication-related incidents reported to a hospital voluntary incident reporting system to identify and quantify the magnitude of wrong dose errors.MethodsThe study was a retrospective review of medication-related incidents reported over a 7-year period at a large acute teaching hospital in the UK, providing secondary and tertiary care for a range of clinical specialties. Medication-related incident reports submitted from all clinical settings were reviewed. Incidents submitted under the categories ‘wrong dose’, ‘wrong dose preparation’, ‘wrong rate’ or ‘wrong quantity’ and describing situations where incorrect doses were prescribed, dispensed or administered were analysed. Magnitudes of medication overdoses and underdoses reported from adult and paediatric settings were calculated. Stage of the medicines process and drug classes most commonly involved in wrong dose errors were described.ResultsOf 12 006 reported medication incidents, 1568 described ‘wrong-dose’ errors: 702 (44.8%) were prescribing errors, 223 (14.2%) were dispensing errors and 643 (41%) were administration errors. Overdoses were reported more frequently than underdoses. 926 (59%) of reported wrong dose errors were overdoses, 464 (29.6%) were underdoses; the magnitude could not be determined in 178 (11.4%) of reports. Twofold and 10-fold overdoses and underdoses were the most commonly reported error magnitude, although dosing errors across a wide range of magnitudes were reported. Incidents were reported from paediatric wards (491, 31.3%), non-paediatric wards and clinical settings (880, 56.1%) and pharmacy (197, 12.6%). Prescribing errors (702, 45.9%) were reported more commonly than administration (643, 41%) and dispensing errors (223, 14.2%). Drugs acting on the central nervous system, cardiovascular drugs and anti-infectives were the drug classes most commonly involved.ConclusionsWrong dose errors occur across all inpatient settings. Wrong dose errors of all magnitudes are possible, but twofold and 10-fold errors occur most frequently. Drug classes involved in wrong dose incidents reported to a voluntary reporting system in a large acute hospital are similar to those identified using other methodologies. Harms and potential harms associated with specific drugs and error magnitudes need to be identified to inform quality improvement work to reduce the risk of patient harm.

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“…An important limitation of our study was the fact that voluntarily reported ME are always underreported [11,18,22], making sound conclusions or statistics based on the number of errors reported not feasible. Second, like all studies on voluntarily reported ME, our study suffered from "selfreport bias", with the consequence that different types of ME were not equally reported [47]. The consequence of this "self-report bias" was that a statistics-based comparison between the different error groups or different settings could not be performed.…”

Section: Limitationsmentioning

confidence: 94%

Voluntarily reported prescribing, monitoring and medication transfer errors in intensive care units in The Netherlands

et al. 2020

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Background Medication errors occur frequently in intensive care units (ICU). Voluntarily reported medication errors form an easily available source of information. Objective This study aimed to characterize prescribing, monitoring and medication transfer errors that were voluntarily reported in the ICU, in order to reveal medication safety issues. Setting This retrospective data analysis study included reports of medication errors from eleven Dutch ICU's from January 2016 to December 2017. Method We used data extractions from the incident reporting systems of the participating ICU's. The reports were transferred into one database and categorized into type of error, cause, medication (groups), and patient harm. Descriptive statistics were used to calculate the proportion of medication errors and the distribution of subcategories. Based on the analysis, ICU medication safety issues were revealed. Main outcome measure The main outcome measure was the proportion of prescribing, monitoring and medication transfer error reports. Results Prescribing errors were reported most frequently (n = 233, 33%), followed by medication transfer errors (n = 85, 12%) and monitoring errors (n = 27, 4%). Other findings were: medication transfer errors frequently caused serious harm, especially the omission of home medication involving the central nervous system and proton pump inhibitors; omissions and dosing errors occurred most frequently; protocol problems caused a quarter of the medication errors; and medications needing blood level monitoring (e.g. tacrolimus, vancomycin, heparin and insulin) were frequently involved. Conclusion This analysis of voluntarily reported prescribing, monitoring and medication transfer errors warrants several improvement measures in these processes, which may help to increase medication safety in the ICU.

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Self report may lead to underestimation of ‘wrong dose’ medication errors

Cited by 6 publications

References 9 publications

Medication Errors in Critically Ill Adults: A Review of Direct Observation Evidence

Medication Errors in Critically Ill Adults: A Review of Direct Observation Evidence

Magnitude of error: a review of wrong dose medication incidents reported to a UK hospital voluntary incident reporting system

Voluntarily reported prescribing, monitoring and medication transfer errors in intensive care units in The Netherlands

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