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ObjectivesOur aim was to review medication-related incidents reported to a hospital voluntary incident reporting system to identify and quantify the magnitude of wrong dose errors.MethodsThe study was a retrospective review of medication-related incidents reported over a 7-year period at a large acute teaching hospital in the UK, providing secondary and tertiary care for a range of clinical specialties. Medication-related incident reports submitted from all clinical settings were reviewed. Incidents submitted under the categories ‘wrong dose’, ‘wrong dose preparation’, ‘wrong rate’ or ‘wrong quantity’ and describing situations where incorrect doses were prescribed, dispensed or administered were analysed. Magnitudes of medication overdoses and underdoses reported from adult and paediatric settings were calculated. Stage of the medicines process and drug classes most commonly involved in wrong dose errors were described.ResultsOf 12 006 reported medication incidents, 1568 described ‘wrong-dose’ errors: 702 (44.8%) were prescribing errors, 223 (14.2%) were dispensing errors and 643 (41%) were administration errors. Overdoses were reported more frequently than underdoses. 926 (59%) of reported wrong dose errors were overdoses, 464 (29.6%) were underdoses; the magnitude could not be determined in 178 (11.4%) of reports. Twofold and 10-fold overdoses and underdoses were the most commonly reported error magnitude, although dosing errors across a wide range of magnitudes were reported. Incidents were reported from paediatric wards (491, 31.3%), non-paediatric wards and clinical settings (880, 56.1%) and pharmacy (197, 12.6%). Prescribing errors (702, 45.9%) were reported more commonly than administration (643, 41%) and dispensing errors (223, 14.2%). Drugs acting on the central nervous system, cardiovascular drugs and anti-infectives were the drug classes most commonly involved.ConclusionsWrong dose errors occur across all inpatient settings. Wrong dose errors of all magnitudes are possible, but twofold and 10-fold errors occur most frequently. Drug classes involved in wrong dose incidents reported to a voluntary reporting system in a large acute hospital are similar to those identified using other methodologies. Harms and potential harms associated with specific drugs and error magnitudes need to be identified to inform quality improvement work to reduce the risk of patient harm.

BackgroundAn adverse drug event (ADE) is a potentially harmful and unintended outcome of medicines use. In the UK, ADE trigger tools have been advocated for detecting ADEs associated with high risk drugs, including opioids. Naloxone is used to reverse opioid toxicity so is a useful indicator of potential opioid related ADEs.PurposeWe aimed to measure the sensitivity of naloxone as a trigger to detect opioid related ADEs in adult inpatients in an acute hospital. The objectives were to: assess the positive predictive value (PPV) of the naloxone trigger; and identify drugs most commonly associated with ADEs.Material and methodsWe conducted a retrospective review of adult inpatients administered naloxone between October 2014 and September 2015. Naloxone doses recorded as administered on our electronic prescribing system (EPMA) were included. A&E, paediatrics and critical care units were excluded. Ethics approval was not required. Case review forms were completed for each patient and reviewed by a multidisciplinary panel who applied the WHO Uppsala Monitoring Centre Causality Assessment System (WHO-UMC CAS) to confirm opioid ADEs. The National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) Index was applied to assign a severity of harm rating to confirmed ADEs.Results142 naloxone trigger events were identified; 17 were excluded. 125 ADEs were categorised by the multidisciplinary panel using the WHO-UMC CAS tool. 91 cases were considered certain (54), probable (13) or possible (24). 34 cases were considered unlikely (8), conditional (1) or unassessable (25). NCCMERP Index harm ratings were applied to the 91 confirmed ADEs: 90 were categorised as E and 1 event which resulted in escalation of care was categorised as F.ConclusionThe PPV of naloxone for opioid ADEs was 72.8% (91/125). This is higher than in other studies which have found rates of 57.6–68.3%, although methodologies vary. Morphine sulphate was most commonly associated with ADEs, accounting for 55/91 ADEs. Incomplete documentation of patients’ clinical status before and after naloxone administration limited case note review. Although time consuming, our methodology could become the gold standard for confirming opioid related ADEs.References and/or acknowledgements1. The Uppsala Monitoring Centre. The use of the WHO-UMC system for standardised case causality assessment. 2012.No conflict of interest