Severity-Indexed, Incident Report-Based Medication Error-Reporting Program

Medication errors in paediatric practice: insights from a continuous quality improvement approach

“…Supply errors were less common (7%), and were due to inadequate provision of stock (n 19), errors made in labelling dispensed medicines (n 5), erroneous entries in the controlled substance log book (n 3), and drug information errors (n 2). Applying the classi®cation of Hartwig et al [16], there were 298 Level 0 errors (68%), 134 Level 1 errors (30%), three Level 2 errors (<1%), ®ve Level 3 errors (1%), and one Level 4 error. Thirty-four Level 1 errors resulted from delayed drug administration, which were judged to be of no clinical signi®cance.…”

“…Errors were classi®ed into three broad categories: prescription errors, administration errors, and supply errors (Table 1) [2,3,17]. Errors were also categorised as serious (capable of producing permanent organ damage or death) or not serious, and outcome was graded according to the classi®cation described by Hartwig et al [16]:…”

“…Adverse incident reporting encourages multidisciplinary co-operation, which is an integral part of the CQI process [11,21]. It has been employed in a variety of hospital settings [16,27,30], and was used in the current study because it was likely to be eective, inexpensive and easy to administer [7,24,28]. The main criticism of the technique is the potential for the under-reporting of errors [15].…”

Analysis of an electronic medication reconciliation and information at discharge programme for frail elderly patients

“…Indicators established by the European WP5 working group were calculated. The severity of reconciliation errors was determined using the National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) classification [23]. This has nine categories ranging from ''A) Circumstances or events that have the capacity to cause error'' to ''I) An error occurred that may have contributed to or resulted in the patient's death''.…”

“…According to the adapted classification of the NCCMERP [23], 26 % (n = 27) of the errors would not have reached the patient (category B); 33 % (n = 35) would have reached the patient, but were unlikely to have caused any harm (category C); 28 % (n = 29) would have reached the patient and would have required monitoring and/or intervention to prevent harm (category D); 11 % (n = 12) would have caused temporary harm (category E); and 2 % (n = 2) would have led to hospitalisation or prolongation of stay (category F). This suggests that 13 % (n = 14) could be considered severe (categories E-I).…”