212: Medication events leading to patient harm in an inpatient obstetrics unit

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According to a report by the Institute of Medicine the average hospitalized patient in the U.S. experiences one medication error every day. Many medications used frequently in obstetrics are classified as high-alert by the Institute for Safe Medication Practices (ISMP) however evaluation of their safe use in practice is largely unknown. The objective of this quality improvement study was to describe errors resulting in patient harm and determine the frequency of patient harm from high-alert medications in our high-risk inpatient obstetrics unit. We performed a retrospective analysis of all medication errors from January 1, 2014 to July 1, 2019 using our institution’s centralized risk management event reporting system. Utilizing the error severity classification system (A–unsafe condition no event, B–Near miss, C-No harm, reached patient no monitoring, D–No harm, reached patient monitoring required, E–Harm, temporary intervention needed & F–Harm, temporary hospitalization/higher level of care needed) we assessed all medication errors with harm events (E & F). All errors were evaluated by event and medication type. During the time analyzed there were 18 medication errors resulting in patient harm. Figure 1 depicts the number of harm events by medication and event type. Magnesium sulfate had the most harm events (n=5) followed by regular insulin (n=2), bupivacaine with sufentanil epidurals (n=2), and gentamicin (n=2). A variety of process steps lead to harm events. Administering an IV infusion medication at the wrong rate was the cause of most errors (n=5) followed by inappropriate doses (n=4) and missed doses (n=3). The 3 most frequent medications leading to harm are listed as high-alert by ISMP. High-alert medications represented 10 of the 18 harm events (Figure 2). Our analysis demonstrates that, although infrequent, medication events leading to patient harm occur in our obstetrics unit. ISMP high-alert drugs were involved in 55% of harm events. These high-alert medications should be prioritized by quality improvement initiatives to reduce errors.View Large Image Figure ViewerDownload Hi-res image Download (PPT)