Severe and fatal medication errors in hospitals: findings from the Norwegian Incident Reporting System

Abstract

Background Even with global efforts to prevent medication errors, they still occur and cause patient harm. Little systematic research has been done in Norway to address this issue. Objectives To describe the frequency, stage and types of medication errors in Norwegian hospitals, with emphasis on the most severe and fatal medication errors. Methods Medication errors reported in 2016 and 2017 (n=3557) were obtained from the Norwegian Incident Reporting System, based on reports from 64 hospitals in 2016 and 55 in 2017. Reports contained categorical data (eg, patient age, incident date) and free text data describing the incident. The errors were classified by error type, stage in the medication process, therapeutic area and degree of harm, using a modified version of the WHO Conceptual Framework for the International Classification for Patient Safety. Results Overall, 3372 reports were included in the study. Most medication errors occurred during administration (68%) and prescribing (24%). The leading types of errors were dosing errors (38%), omissions (23%) and wrong drug (15%). The therapeutic areas most commonly involved were analgesics, antibacterials and antithrombotics. Over half of all errors were harmful (62%), of which 5.2% caused severe harm, and 0.8% were fatal. Conclusions Medication errors most commonly occurred during medication administration. Dosing errors were the most common error type. The substantial number of severe and fatal errors causing preventable patient harm and death emphasises an urgent need for error-prevention strategies. Additional studies and interventions should further investigate the error-prone medication administration stage in hospitals and explore the dynamics of severe incidents.

Perceptions of Patient Safety Culture and Medication Error Reporting among Early- and Mid-Career Female Nurses in South Korea

“…Another study suggested that 63.6% of patients reported medication errors in acute care hospital settings [ 19 ]. Under-reporting or lack of emphasis on accurate medication error-reporting may be one of the major issues for the variation in the medication error rates [ 12 , 20 ]. Undoubtedly, low and inaccurate reporting of medication errors interferes with the identification and prevention of causes, limiting opportunities to improve patient safety by understanding and sharing knowledge on error detection and safe practices [ 11 , 16 ].…”

“…Some evidence has revealed that early-career nurses seek employment in nursing environments with a focus on quality patient care [ 33 , 34 , 35 ]. Despite the importance of error communication, the actual amount of error reporting is lower than the number of actual medication errors determined by experts [ 11 , 20 ]. Thus, understanding perceived barriers to error reporting, from the nurses’ perspective, is crucial in promoting reporting behavior.…”

Legemiddelavvik hos pasienter innlagt i sykehus

“…Avvikene ble rapportert uten risiko for sanksjoner. En gjennomgang av 3 372 legemiddelavvik som ble rapportert til meldeordningen i 2016 og 2017 (5), viste at 68 % av avvikene forekom ved utdeling, 24 % ved ordinering og 6 % ved istandgjøring. De vanligste avvikstypene var doseavvik (38 %), glemt legemiddel (23 %) og feil legemiddel (15 %).…”

“…Våre tall stemmer relativt godt overens med resultatene fra den forrige undersøkelsen (9), og også med det som ble rapportert til meldeordningen i årene 2016-17 (5). Selv om meldeordningen har mottatt rapporter fra rundt 60 ulike sykehus og vi kun har sett på ett, var det små forskjeller i andelen rapporter mellom studiene for sentrale avviksgrupper som doseringsavvik, at det var gitt et annet legemiddel enn ordinert og at legemidlet var gitt til en annen pasient.…”

“…Hvilke prinsipielle typer legemiddelavvik som oppstår, er godt kjent og ser også ut til å opptre konstant over tid. Våre funn stemmer godt overens med internasjonal litteratur (3, 4) og en annen nyere norsk studie (5). Likevel har avviksrapportering en viktig funksjon med tanke på å identifisere avdelingsspesifikke forhold.…”