5PSQ-059 Characterisation of medication errors in a public hospital

Abstract

<h3>Background and importance</h3> Health care is associated with risk management in which we include medication errors. These remain a major cause of morbidity and mortality. In 2017, the World Health Organization launched the Global Patient Safety Challenge: Medication Without Harm, the goal of which is to globally reduce the level of severe, avoidable harm related to medications by 50% over 5 years. <h3>Aim and objectives</h3> Characterisation of medication errors according to the National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) Index. <h3>Material and methods</h3> An observational, descriptive and retrospective study was conducted over 2 years. This study included all prescriptions with at least one pharmaceutical intervention conducted on inpatients admitted from 1 January 2019 to 31 December 2020 and it was based on pharmaceutical records and clinical files. The identified medication errors were categorised according to the NCCMERP Index (Category A: no error; Category B, C, D: error, no harm; Category E, F, G, H: error, harm and Category I: error, death). The medication errors that could not be categorised according to the NCCMERP Index due to omission of information were excluded. <h3>Results</h3> From a total of 8076 pharmaceutical interventions, it was possible to categorise 1831 medication errors. According to the NCCMERP categories the following distribution was found: 57.67% (1056/1831) Category A; 15.78% (289/1831) Category B; 19.93% (365/1831) Category C; 3.77% (69/1831) Category D; 2.51% (46/1831) Category E; 0.16% (3/1831) Category F; 0% Category G; 0.05% (1/1831) Category H; and 0.11% (2/1831) Category I. These results include 57.67% with no error, 39.48% with error and no harm, 2.72% with error and harm and 0.11% with error and death. The medication errors from Categories E to I involved 16 medications. Acenocoumarol and enoxaparin were the drugs involved in the errors that led to death. <h3>Conclusion and relevance</h3> Characterising medication errors is essential to identify system failures and their severity. Evidence suggests that knowledge can improve perception of safety culture and potentially reduce patient harm. The pharmacist is a core element in the health care system, improving patient safety and care quality, by raising awareness of medication management among other healthcare providers. The overall challenge is to identify the weaknesses at each stage of the medication process and find strategies to avoid them and/or minimise their frequency and impact. <h3>References and/or acknowledgements</h3> 1–16 MedicationPrintFinalNew2 (who.int) https://www.nccmerp.org/sites/default/files/indexColor2001-06-12.pdf <h3>Conflict of interest</h3> No conflict of interest