PS-023 Types, causes and potential seriousness of medicines errors intercepted by medicines reconciliation in a general hospital

Abstract

Background As part of the WHO’s High 5s project, the Standard Operating Protocol “Medicines Reconciliation” has been used in our hospital centre since 2010. Medicines reconciliation at the time of admission detects medicines errors (ME), called unintended discrepancies (UDs). These MEs are particularly worthy of attention because they are not detected by the computerised physician order entry system (CPOES). Purpose To analyse the type and the potential seriousness of MEs, to identify the cause of the loss of information and to determine the ATC groups of the drugs most involved. Material and methods Prospective observational and interventional study. From July to September 2014 In patients older than 65 years of age hospitalised in short stay units after admission through the Emergency Department: Within 48 h of admission, patients’ regularly used medicines are compared with computerised prescriptions at admission. Every UD identified is corrected at reconciliation, and recorded in an Excel file. Results 191 lines of UDs were identified among 532 reconciled patients (30% from eligible patients): Type of ME: omission (70%), incorrect dose (20%) Potential seriousness: minor (32%), significant (48%), major+ (20%) Identified cause: inattention (60%), regular prescriptions non-available (26%), resumption of an old prescription (7%) Most involved ATC groups: C (35%) particularly subgroups C09 (30%) and C10 (30%). Conclusion Most MEs are omissions, and information is most frequently lost due to inattention; this is easily corrected by reconciliation. Almost half of MEs might have significant consequences for patients if not rectified. Concerning errors in the C09 subgroup, we must improve the equivalence database of our CPOES. Working within a multidisciplinary team in hospitalisation units, the pharmacist contributes to increasing patient safety. Medicines reconciliation is a time-consuming activity; to keep it steady in our hospital after the end of the WHO project and to be exhaustive, we have to identify which patients are the most important to reconcile. References and/or acknowledgements No conflict of interest.