Detection of Medication Errors in Primary Care Units through Passive Voluntary Reporting Forms

Rowan Ahmed,Amr Saad,Manal El Hamamsy,Nagwa Sabri

doi:10.21608/aps.2019.45300

Abstract

The lack of a universally accepted terminology of what constitutes a Medication Error (ME), makes it difficult to report, detect, categorize and prevent MEs. Methodologically, there isn't a complete picture of the incidence and prevalence of MEs. The broad range of ME rates in literature reflects heterogeneity in the study designs and detection methods used. The current study aimed to detect MEs in reports received from Primary Care Units. A retrospective analysis was applied on such reports dated from March to November 2013 and some fatal cases are taken from 2014. All voluntary reports were included, excluded were errors not associated with drug use and pharmaceutical company reports. Eligible reports underwent assessment using predetermined criteria to pick up MEs. The criteria were applicable on 115 reports, in which MEs were detected. 60% (69/ 115) of ME cases were error cluster while 40% (46/115) were unknown due to either underreporting, lack of data or poor observation and correlation (p < 0.05). Only 7% (8/115) p < 0.001 of the reports were pregnancy cases. Moreover, errors associated with vaccine use accounted for 7% (8/115) of the cases while 93% accounted for errors from other drug use at p < 0.001. Long-term follow-up was needed but not done by the assessors in 41% (47 of 115) of ME cases at pvalue=0.05. Attachments were provided with the reports in 9% (10 /115) of the cases while the majority 91% (105/115) were not (p < 0.001). In conclusion, voluntary reporting is a major strategy to prevent MEs by learning from errors reported.

Highlights

According to recent studies, medical errors may account for as many as 251,000 deaths yearly in the United States (U.S), making them the third most important cause of death after heart disease and cancer [1]
The definition indicates that the treatment process fell under some achievable benchmark with regard to therapy, case investigation, prevention and that the error may not lead to harm
A retrospective analysis was applied on reports dated from March to November 2013 and additional reports dated in 2014 which were received from primary care units including different hospitals, health care units, health centers, outpatient clinics and pharmacies in Alexandria, Egypt

Summary

Introduction

Medical errors may account for as many as 251,000 deaths yearly in the United States (U.S), making them the third most important cause of death after heart disease and cancer [1]. According to FDA, among the most common medical errors are medication errors (ME); more than 1.5 million people are harmed annually by ME in hospitals, caring homes, and clinics according to a report from the Institute of Medicine [2]. Medication Error is defined as "a failure in the treatment process that leads to or has the potential to lead to, harm to the patient" [7]. The definition indicates that the treatment process fell under some achievable benchmark with regard to therapy, case investigation, prevention and that the error may not lead to harm. The definition provides a chance for the surveillance of medicines [6]

Methods

Discussion

Conclusion