Abstract
Background: Hospital-acquired medication errors (MEs) are common in health care. Although voluntary reporting is criticized for not producing reliable estimates on ME frequency, it provides valuable knowledge on errors occurring in the medication process.Objective: The purpose of this study was to analyze and determine the risks and outcomes resulting from MEs related to the TOP15 medicines in the Finnish tertiary care units from July 2016 to July 2017.Methods: The data consisting of 1,447 ME reports was organized according to ATC classification, after which TOP15 medicines involved in the reports were selected. Inductive content analysis was performed to the reports. After this, the reports were categorized by ME outcome into five categories and further analyzed accordingly.Results: The most common ME outcome in the reports was “omitted medicine” (33.9%). More than a quarter (27.1%) of ME reports were estimated to cause moderate or severe risk to the patient. When compared with each other, none of the outcome groups were more susceptible to high-risk events (p = 0.71). Of the TOP15 medicines, only Norepinephrine had significantly higher risk of being involved in high-risk events (OR 2.43, 95%CI 1.35–4.61).Conclusion: Voluntary reporting has an important role in the development of medication safety and the overall medication process within organizations. Although majority of the TOP15 medicines were involved in MEs resulting in seemingly high-risk outcomes, they were estimated to be insignificant or minor within the reporting unit. In the future, more emphasis will be needed for the assessment and analysis of the reports for more efficient, real-time detection and response to signals from health care units.
Highlights
Medication errors (MEs) are highly common in an in-hospital setting (Kaushal et al, 2001; Rothschild et al, 2007; Aronson, 2009; Carayon et al, 2014; Aibar, et al, 2015; Härkänen et al., 2018)
To minimize the bias caused by this, the analyses of medicine-specific risk and medicinal outcome was conducted with only the reports that included one TOP15 medicine
The events reported for Norepinephrine were undeniably severe, similar estimates could be made for the incidents involving the other TOP15 medicines as well: The most common errors including fast-acting insulin (Novorapid ® ) were the administration of insulin to a wrong patient or confusing it with another medicine due to LASA-errors—both incidents that have been linked to severe consequences in the past (Classen et al, 2010; Geller et al, 2014)
Summary
Medication errors (MEs) are highly common in an in-hospital setting (Kaushal et al, 2001; Rothschild et al, 2007; Aronson, 2009; Carayon et al, 2014; Aibar, et al, 2015; Härkänen et al., 2018). They can occur at any stage of medication process, from prescribing to handling and administering. Voluntary reporting is criticized for not producing reliable estimates on ME frequency, it provides valuable knowledge on errors occurring in the medication process
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